Provider Demographics
NPI:1194776930
Name:SUBLETTE COUNTY RURAL HEALTH CARE DISTRICT
Entity type:Organization
Organization Name:SUBLETTE COUNTY RURAL HEALTH CARE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GATZKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-276-4451
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:BIG PINEY
Mailing Address - State:WY
Mailing Address - Zip Code:83113-0787
Mailing Address - Country:US
Mailing Address - Phone:307-276-4451
Mailing Address - Fax:307-276-4447
Practice Address - Street 1:625 E HENNICK
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-4133
Practice Address - Fax:307-367-6636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBLETTE COUNTY RURAL HEALTH CARE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-15
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121421700Medicaid
WYW20339Medicare PIN