Healthcare Provider Details

I. General information

NPI: 1003440082
Provider Name (Legal Business Name): SNAKE RIVER COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 10TH ST
LEWISTON ID
83501-1910
US

IV. Provider business mailing address

PO BOX 6
LEWISTON ID
83501-0006
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-5899
  • Fax: 208-743-9130
Mailing address:
  • Phone: 208-743-5899
  • Fax: 208-743-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE ASH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-743-5899