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General NPI Number Information
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NPI Number | 1548909153
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Entity Type | Organization
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Legal Business Name | CLEAN CLINIC WYOMING
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Dates
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Enumeration Date | 06/01/2022
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Last Update Date | 02/17/2024
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Provider Practice Location Address
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Address Line | 1918 THOMES AVE
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City | CHEYENNE
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State | WY
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Zip | 82001-3527
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Country | US
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Telephone | 928-242-9929
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Fax |
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Provider Business Mailing Address
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Address Line | 63 E 11400 S # 275
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City | SANDY
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State | UT
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Zip | 84070-6705
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Country | US
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Telephone | 801-946-4045
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. LORENCE A HARMER
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Credential |
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Telephone | 801-946-4045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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