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General NPI Number Information
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NPI Number | 1194056127
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Entity Type | Organization
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Legal Business Name | WAMSUTTER COMMUNITY HEALTH CENTER26-
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Dates
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Enumeration Date | 01/14/2010
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Last Update Date | 01/15/2010
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Provider Practice Location Address
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Address Line | 401 FULTZ DRIVE
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City | WAMSUTTER
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State | WY
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Zip | 82336
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Country | US
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Telephone | 307-328-0468
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Fax | 307-324-9438
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Provider Business Mailing Address
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Address Line | PO BOX 208
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City | WAMSUTTER
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State | WY
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Zip | 82336
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Country | US
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Telephone | 307-328-0468
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Fax | 307-324-9438
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MARVIN WAYNE COUCH II
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Credential | MD
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Telephone | 307-324-6002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5629A
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 279
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License Number State | WY
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