Healthcare Provider Details

I. General information

NPI: 1194792457
Provider Name (Legal Business Name): RED ROCK FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N C AVE
THERMOPOLIS WY
82443-2410
US

IV. Provider business mailing address

120 N C AVE
THERMOPOLIS WY
82443-2410
US

V. Phone/Fax

Practice location:
  • Phone: 307-864-5534
  • Fax: 307-864-9470
Mailing address:
  • Phone: 307-864-5534
  • Fax: 307-864-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WADE TRAVIS BOMENGEN
Title or Position: OWNER
Credential: M.D.
Phone: 307-864-5534