Provider Demographics
NPI:1366108425
Name:JCILOA
Entity type:Organization
Organization Name:JCILOA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-331-3703
Mailing Address - Street 1:1000 ERWIN ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2914
Mailing Address - Country:US
Mailing Address - Phone:307-331-3703
Mailing Address - Fax:
Practice Address - Street 1:1000 ERWIN ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2914
Practice Address - Country:US
Practice Address - Phone:307-331-3703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-12
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility