Provider Demographics
NPI:1053989103
Name:WYOMING PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:WYOMING PHYSICAL THERAPY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-772-0955
Mailing Address - Street 1:1217 S GREELEY HWY STE A
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-3063
Mailing Address - Country:US
Mailing Address - Phone:307-772-0955
Mailing Address - Fax:
Practice Address - Street 1:910 E EISENHOWER BLVD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3922
Practice Address - Country:US
Practice Address - Phone:970-541-2851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty