Provider Demographics
NPI:1699292391
Name:WIND RIVER CARES RIVERTON
Entity type:Organization
Organization Name:WIND RIVER CARES RIVERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-856-9281
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:307-349-0868
Mailing Address - Fax:307-856-1630
Practice Address - Street 1:511 NORTH 12 STREET EAST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-463-4610
Practice Address - Fax:307-856-1630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WIND RIVER FAMILY & COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-24
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY142138700Medicaid