Provider Demographics
NPI:1588149983
Name:WYOMING CLINIC OF CHIROPRACTIC LC
Entity type:Organization
Organization Name:WYOMING CLINIC OF CHIROPRACTIC LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:DREW
Authorized Official - Last Name:REDINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-461-2716
Mailing Address - Street 1:528 COFFEEN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5312
Mailing Address - Country:US
Mailing Address - Phone:307-461-2716
Mailing Address - Fax:
Practice Address - Street 1:528 COFFEEN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5312
Practice Address - Country:US
Practice Address - Phone:307-461-2716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYOMING CLINIC OF CHIROPRACTIC LC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY785OtherSTATE LICENSE NUMBER