Healthcare Provider Details

I. General information

NPI: 1205369576
Provider Name (Legal Business Name): ICBM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 RED TAIL DR
ROCK SPRINGS WY
82901-5879
US

IV. Provider business mailing address

126 ELK ST
ROCK SPRINGS WY
82901-5241
US

V. Phone/Fax

Practice location:
  • Phone: 307-362-6029
  • Fax: 307-362-2379
Mailing address:
  • Phone: 307-362-6029
  • Fax: 307-362-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. ELINA CHERNYAK
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 970-306-2737