Provider Demographics
NPI:1053503565
Name:FRONTIER WYOMING, L.L.C.
Entity type:Organization
Organization Name:FRONTIER WYOMING, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOGUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-693-3840
Mailing Address - Street 1:53 RIVER ST
Mailing Address - Street 2:YANKEE PROFESSIONAL BUILDING
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3346
Mailing Address - Country:US
Mailing Address - Phone:203-693-3840
Mailing Address - Fax:203-693-3841
Practice Address - Street 1:230 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2838
Practice Address - Country:US
Practice Address - Phone:307-332-2922
Practice Address - Fax:307-332-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
WY0713203251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1053503565Medicaid
WY537041AMedicare Oscar/Certification