Healthcare Provider Details

I. General information

NPI: 1326957853
Provider Name (Legal Business Name): DEREK CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4304 AIRPORT RD
RIVERTON WY
82501-9210
US

IV. Provider business mailing address

4304 AIRPORT RD
RIVERTON WY
82501-9210
US

V. Phone/Fax

Practice location:
  • Phone: 307-851-2770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: