Provider Demographics
NPI:1194792457
Name:RED ROCK FAMILY PRACTICE, PC
Entity type:Organization
Organization Name:RED ROCK FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:BOMENGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-864-5534
Mailing Address - Street 1:120 N C AVE
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2410
Mailing Address - Country:US
Mailing Address - Phone:307-864-5534
Mailing Address - Fax:307-864-9470
Practice Address - Street 1:120 N C AVE
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2410
Practice Address - Country:US
Practice Address - Phone:307-864-5534
Practice Address - Fax:307-864-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116973400Medicaid
WY116973402Medicaid
WY53D0996144OtherCLIA
WY116973402Medicaid