Healthcare Provider Details

I. General information

NPI: 1649156142
Provider Name (Legal Business Name): SNAKE RIVER WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 N COMMERCIAL ST
GLENNS FERRY ID
83623-2342
US

IV. Provider business mailing address

PO BOX 102
GLENNS FERRY ID
83623-0102
US

V. Phone/Fax

Practice location:
  • Phone: 208-366-1200
  • Fax:
Mailing address:
  • Phone: 208-366-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: CARIN M HOWARD
Title or Position: OWNER
Credential: PA-C
Phone: 208-366-1200