MEDICARE: WYOMED LABORATORY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory		WY

General Provider Information

NPI Number	:	1972658250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYOMED LABORATORY, INC

Provider Business Mailing Address
First Line	:	204 MCCOLLUM ST STE 105
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5151
Country	:	US
Telephone Number	:	307-721-5111
Fax Number	:	307-745-5732

Provider Business Practice Location Address
First Line	:	204 MCCOLLUM ST STE 105
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5151
Country	:	US
Telephone Number	:	307-721-5111
Fax Number	:	307-745-5732

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. GEORGIA JEAN CARMIN
Credential	:	MT(ASCP)
Telephone Number	:	307-721-5111

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	08/22/2020

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