Provider Demographics
NPI:1194056127
Name:WAMSUTTER COMMUNITY HEALTH CENTER26-
Entity type:Organization
Organization Name:WAMSUTTER COMMUNITY HEALTH CENTER26-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:COUCH II
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-324-6002
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:WAMSUTTER
Mailing Address - State:WY
Mailing Address - Zip Code:82336
Mailing Address - Country:US
Mailing Address - Phone:307-328-0468
Mailing Address - Fax:307-324-9438
Practice Address - Street 1:401 FULTZ DRIVE
Practice Address - Street 2:
Practice Address - City:WAMSUTTER
Practice Address - State:WY
Practice Address - Zip Code:82336
Practice Address - Country:US
Practice Address - Phone:307-328-0468
Practice Address - Fax:307-324-9438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5629A207Q00000X
WY279363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty