Provider Demographics
NPI:1023285962
Name:THAD'S HOUSE, LLC
Entity type:Organization
Organization Name:THAD'S HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THAD
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:307-333-4671
Mailing Address - Street 1:PO BOX 50141
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82605-0141
Mailing Address - Country:US
Mailing Address - Phone:307-333-4671
Mailing Address - Fax:
Practice Address - Street 1:636 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2004
Practice Address - Country:US
Practice Address - Phone:307-333-4671
Practice Address - Fax:307-472-1713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT 234324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility