53D2129489 CLIA NUMBER - STAR VALLEY MEDICAL CENTER - THAYNE CLINIC

Laboratory Demographics

CLIA Number: 53D2129489

Facility Name: STAR VALLEY MEDICAL CENTER - THAYNE CLINIC

Facility Address:
122 PETERSEN PARKWAY
THAYNE, WY
ZIP 83127
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Facility Phone Number: 307 885-5827

Facility Type: Community Clinic

Certificate Type: Microscopy

NPI Number: 1821610957

Taxonomy: 1223S0112X - Dentist
An oral and maxillofacial surgery dentist specialized in the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.

CLIA Record

Field Name	Field Value
CLIA Number	53D2129489
LAB Type	Community Clinic
Facility Name	STAR VALLEY MEDICAL CENTER - THAYNE CLINIC
Street	122 PETERSEN PARKWAY
City	THAYNE
State	WY
ZIP	83127
Phone	307 885-5827
CertificateType	3
CertificateEffectiveDate	4/20/2023
CertificateExpirationDate	4/19/2025
FacilityType	PPMP

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This page was last updated on: 4/23/2024