Healthcare Provider Details

I. General information

NPI: 1154528099
Provider Name (Legal Business Name): SNAKE RIVER REHABILITATION COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 23RD AVE STE 301B
LEWISTON ID
83501-6357
US

IV. Provider business mailing address

1630 23RD AVE STE 301B
LEWISTON ID
83501-6357
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-5101
  • Fax: 208-746-5282
Mailing address:
  • Phone: 208-743-5101
  • Fax: 208-746-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA LEE CUNNINGHAM
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-743-5101