Organization
JCILOA
Active
Other names
Edward Michael Tucker JILOA
Organization subpart
No
Provider details
NPI number
Authorized official
EDWARD MICHAEL TUCKER (OWNER)
(307) 331-3703
Entity
Organization
Contact information
Practice address
1000 ERWIN ST, DOUGLAS, WY 82633-2914
(307) 331-3703
Mailing address
1000 ERWIN ST, DOUGLAS, WY 82633-2914
(307) 331-3703
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Enumeration date
11/12/2021
Last updated
07/02/2022
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