Provider Demographics
NPI:1407835960
Name:HOSPICE OF LARAMIE
Entity type:Organization
Organization Name:HOSPICE OF LARAMIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGHURST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-745-9254
Mailing Address - Street 1:1754 CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-8417
Mailing Address - Country:US
Mailing Address - Phone:307-745-9254
Mailing Address - Fax:307-742-5967
Practice Address - Street 1:1754 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-8417
Practice Address - Country:US
Practice Address - Phone:307-745-9254
Practice Address - Fax:307-742-5967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251G00000X
WY0713111251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY111731900Medicaid
531509Medicare ID - Type Unspecified