Healthcare Provider Details

I. General information

NPI: 1922838028
Provider Name (Legal Business Name): WYOMING WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 NIOBRARA AVE
TORRINGTON WY
82240-1522
US

IV. Provider business mailing address

601 NIOBRARA AVE
TORRINGTON WY
82240-1522
US

V. Phone/Fax

Practice location:
  • Phone: 307-532-3035
  • Fax: 307-275-9533
Mailing address:
  • Phone: 307-532-3035
  • Fax: 307-275-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: TRACY RENE' RICHARD
Title or Position: OWNER / PROVIDER
Credential: CRNA
Phone: 307-532-3035