Provider Demographics
NPI:1902097637
Name:SPINE & INJURY CLINIC OF LARAMIE, PC
Entity Type:Organization
Organization Name:SPINE & INJURY CLINIC OF LARAMIE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-742-2082
Mailing Address - Street 1:3905 E GRAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5189
Mailing Address - Country:US
Mailing Address - Phone:307-742-2082
Mailing Address - Fax:307-742-2075
Practice Address - Street 1:3905 E GRAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5189
Practice Address - Country:US
Practice Address - Phone:307-742-2082
Practice Address - Fax:307-742-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY663111N00000X
111N00000X, 111NS0005X, 225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty