Provider Demographics
NPI:1669606943
Name:CANYON RIVER STAFFING
Entity type:Organization
Organization Name:CANYON RIVER STAFFING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:THURSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:1307-413-6909
Mailing Address - Street 1:PO BOX 14622
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-4622
Mailing Address - Country:US
Mailing Address - Phone:130-741-3690
Mailing Address - Fax:
Practice Address - Street 1:265 BLAIR DR
Practice Address - Street 2:APT A
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:130-741-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY18595251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251J00000XAgenciesNursing Care