=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508922568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATWOOD FAMILY FUNERAL DIRECTORS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 04/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 419 WEST C STREET
-----------------------------------------------------
City | BASIN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82410-0460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-568-2041
-----------------------------------------------------
Fax | 307-568-2727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 460 419 WEST C STREET
-----------------------------------------------------
City | BASIN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82410-0460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-568-2041
-----------------------------------------------------
Fax | 307-568-2727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AMBULANCE DIRECTOR FUNERA
-----------------------------------------------------
Name | MR. DELMAR W ATWOOD JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 307-568-2041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 176P00000X
-----------------------------------------------------
Taxonomy Name | Funeral Director
-----------------------------------------------------
License Number | 15
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 6
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------