Provider Demographics
NPI:1588688006
Name:STAR VALLEY MEDICAL
Entity type:Organization
Organization Name:STAR VALLEY MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON-MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-883-3445
Mailing Address - Street 1:PO BOX 4156
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:WY
Mailing Address - Zip Code:83112-0156
Mailing Address - Country:US
Mailing Address - Phone:307-883-3445
Mailing Address - Fax:307-883-3472
Practice Address - Street 1:180 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127-9999
Practice Address - Country:US
Practice Address - Phone:307-883-3445
Practice Address - Fax:307-883-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114866400Medicaid
WY1272870001Medicare NSC