Provider Demographics
NPI:1598011306
Name:ALTA VISTA CENTER FOR INTEGRATIVE MEDICINE, LLC
Entity type:Organization
Organization Name:ALTA VISTA CENTER FOR INTEGRATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:FITTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-399-3119
Mailing Address - Street 1:313 S 2ND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3611
Mailing Address - Country:US
Mailing Address - Phone:307-399-3119
Mailing Address - Fax:866-827-3930
Practice Address - Street 1:313 S 2ND ST
Practice Address - Street 2:SUITE B
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3611
Practice Address - Country:US
Practice Address - Phone:307-399-3119
Practice Address - Fax:866-827-3930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7766A208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty