Provider Demographics
NPI:1538581137
Name:DUBOIS ASSISTED LIVING, INC
Entity type:Organization
Organization Name:DUBOIS ASSISTED LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, FNP-BC,
Authorized Official - Phone:307-455-2645
Mailing Address - Street 1:PO BOX 1839
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:WY
Mailing Address - Zip Code:82513-1839
Mailing Address - Country:US
Mailing Address - Phone:307-455-2645
Mailing Address - Fax:307-455-2647
Practice Address - Street 1:5643 US HIGHWAY 26
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:WY
Practice Address - Zip Code:82513-1839
Practice Address - Country:US
Practice Address - Phone:307-455-2645
Practice Address - Fax:307-455-2647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYP0713-106310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP0713-106OtherASSISTED LIVING PROVISIONAL LICENSE NUMBER