Provider Demographics
NPI:1972740397
Name:STAR VALLEY HOME OXYGEN
Entity type:Organization
Organization Name:STAR VALLEY HOME OXYGEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:WALTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-883-3445
Mailing Address - Street 1:118 S. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127
Mailing Address - Country:US
Mailing Address - Phone:307-883-3445
Mailing Address - Fax:307-883-7584
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-3445
Practice Address - Fax:307-883-7584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY6267540001Medicare NSC