Healthcare Provider Details

I. General information

NPI: 1194056127
Provider Name (Legal Business Name): WAMSUTTER COMMUNITY HEALTH CENTER26-
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 FULTZ DRIVE
WAMSUTTER WY
82336
US

IV. Provider business mailing address

PO BOX 208
WAMSUTTER WY
82336
US

V. Phone/Fax

Practice location:
  • Phone: 307-328-0468
  • Fax: 307-324-9438
Mailing address:
  • Phone: 307-328-0468
  • Fax: 307-324-9438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5629A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number279
License Number StateWY

VIII. Authorized Official

Name: MARVIN WAYNE COUCH II
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 307-324-6002