Healthcare Provider Details

I. General information

NPI: 1578949533
Provider Name (Legal Business Name): AMARIS SPANG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 E MAIN ST
RIVERTON WY
82501-3730
US

IV. Provider business mailing address

1008 E MAIN ST
RIVERTON WY
82501
US

V. Phone/Fax

Practice location:
  • Phone: 406-679-3157
  • Fax: 307-332-9446
Mailing address:
  • Phone: 406-679-3157
  • Fax: 307-332-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number35707
License Number StateWY

VIII. Authorized Official

Name: AMARIS E SPANG
Title or Position: NURS
Credential: RN
Phone: 406-679-3157