Provider Demographics
NPI:1588697742
Name:CASPER HEALTHCARE LLC
Entity type:Organization
Organization Name:CASPER HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOERBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-873-7907
Mailing Address - Street 1:60 MAGNOLIA
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-3801
Mailing Address - Country:US
Mailing Address - Phone:307-234-9381
Mailing Address - Fax:307-234-6205
Practice Address - Street 1:60 MAGNOLIA
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-3801
Practice Address - Country:US
Practice Address - Phone:307-234-9381
Practice Address - Fax:307-234-6205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10216314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106292100Medicaid
WY106292100Medicaid