Healthcare Provider Details

I. General information

NPI: 1700344595
Provider Name (Legal Business Name): SNAKE RIVER HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2088 E 25TH ST
IDAHO FALLS ID
83404-6490
US

IV. Provider business mailing address

2088 E 25TH ST
IDAHO FALLS ID
83404-6490
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-7721
  • Fax:
Mailing address:
  • Phone: 208-313-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: SLOAN N SWENDSEN
Title or Position: OWNER
Credential:
Phone: 208-313-7721