Provider Demographics
NPI:1366289290
Name:PPM WYOMING LLC
Entity type:Organization
Organization Name:PPM WYOMING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:TUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-1400
Mailing Address - Street 1:1916 N 700 W STE 110
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5754
Mailing Address - Country:US
Mailing Address - Phone:385-427-1570
Mailing Address - Fax:
Practice Address - Street 1:770 S WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-5135
Practice Address - Country:US
Practice Address - Phone:888-253-6598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty