Healthcare Provider Details

I. General information

NPI: 1720489396
Provider Name (Legal Business Name): SNAKE RIVER PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2014
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NW 12TH ST
FRUITLAND ID
83619-5040
US

IV. Provider business mailing address

1100 NW 12TH ST
FRUITLAND ID
83619-5040
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-6556
  • Fax: 541-216-6557
Mailing address:
  • Phone: 208-452-6556
  • Fax: 541-216-6557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberPA00913
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW JOSEPH BERRIA
Title or Position: PRESIDENT
Credential: PHD, PA-C
Phone: 208-740-4518