Healthcare Provider Details

I. General information

NPI: 1699292391
Provider Name (Legal Business Name): WIND RIVER CARES RIVERTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 NORTH 12 STREET EAST
RIVERTON WY
82501
US

IV. Provider business mailing address

PO BOX 1310
RIVERTON WY
82501
US

V. Phone/Fax

Practice location:
  • Phone: 307-463-4610
  • Fax: 307-856-1630
Mailing address:
  • Phone: 307-349-0868
  • Fax: 307-856-1630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD B BRANNAN
Title or Position: CEO
Credential:
Phone: 307-856-9281