Organization Name: | EASTERN SHOSHONE RECOVERY |
NPI Number: | 1265751309 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | KELLIE R WEBB (RECOVERY PROGRAM DIRECTOR) |
Mailing Address: | #7 Shipton Lane Fort Washakie |
State: | WY US |
Postal Code: | 825140538 |
Phone Number: | 3073351169 |
Fax Number: | 3073351170 |
NPI Enumeration Date: | 05/28/2010 |
NPI Last Update Date: | 05/31/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QR0405X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WY |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Rehabilitation, Substance Use Disorder |
Taxonomy Definition: |