Provider Demographics
NPI:1427648534
Name:S48WY4, LLC
Entity type:Organization
Organization Name:S48WY4, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-265-3791
Mailing Address - Street 1:606 23RD ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5127
Mailing Address - Country:US
Mailing Address - Phone:307-324-8820
Mailing Address - Fax:307-333-0261
Practice Address - Street 1:606 23RD ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5127
Practice Address - Country:US
Practice Address - Phone:307-324-8820
Practice Address - Fax:307-333-0261
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:S48WY1, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder