Healthcare Provider Details

I. General information

NPI: 1740215227
Provider Name (Legal Business Name): JEFFREY L MCMENAMY OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W MAIN ST
RIVERTON WY
82501-3342
US

IV. Provider business mailing address

820 W MAIN ST
RIVERTON WY
82501-3342
US

V. Phone/Fax

Practice location:
  • Phone: 307-857-7074
  • Fax: 307-856-6459
Mailing address:
  • Phone: 307-857-7074
  • Fax: 307-856-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR - 301
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: