Provider Demographics
NPI:1548909153
Name:CLEAN CLINIC WYOMING
Entity type:Organization
Organization Name:CLEAN CLINIC WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-946-4045
Mailing Address - Street 1:63 E 11400 S # 275
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-6705
Mailing Address - Country:US
Mailing Address - Phone:801-946-4045
Mailing Address - Fax:
Practice Address - Street 1:1918 THOMES AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3527
Practice Address - Country:US
Practice Address - Phone:928-242-9929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty