Provider Demographics
NPI:1386396935
Name:STATE OF WYOMING
Entity type:Organization
Organization Name:STATE OF WYOMING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-684-5511
Mailing Address - Street 1:700 VETERANS LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-9402
Mailing Address - Country:US
Mailing Address - Phone:307-684-5511
Mailing Address - Fax:307-684-7636
Practice Address - Street 1:700 VETERANS LN
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-9402
Practice Address - Country:US
Practice Address - Phone:307-684-5511
Practice Address - Fax:307-684-7636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF WYOMING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-25
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility