Provider Demographics
NPI:1871965095
Name:HVIZDAK, DOMINIC
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:HVIZDAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1073
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0119
Mailing Address - Country:US
Mailing Address - Phone:307-851-3894
Mailing Address - Fax:
Practice Address - Street 1:107 S BROADWAY AVE
Practice Address - Street 2:205
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4300
Practice Address - Country:US
Practice Address - Phone:307-851-3894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker