Organization Name: | RED ROCK FAMILY PRACTICE PC |
NPI Number: | 1316914922 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | WADE TRAVIS BOMENGEN (OWNER) |
Mailing Address: | 120 N C Ave Thermopolis |
State: | WY US |
Postal Code: | 824432410 |
Phone Number: | 3078645534 |
Fax Number: | 3078649470 |
NPI Enumeration Date: | 03/02/2006 |
NPI Last Update Date: | 06/07/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QR1300X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Rural Health |
Taxonomy Definition: |