Healthcare Provider Details

I. General information

NPI: 1477144160
Provider Name (Legal Business Name): S48WY4, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 23RD ST
RAWLINS WY
82301-5127
US

IV. Provider business mailing address

231 S WILSON ST
CASPER WY
82601-2941
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-8820
  • Fax:
Mailing address:
  • Phone: 307-265-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMANDA CONSTANTINO
Title or Position: HUMAN RESOURCES
Credential:
Phone: 307-265-3791