Healthcare Provider Details

I. General information

NPI: 1063769297
Provider Name (Legal Business Name): SNAKE RIVER PODIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 RIDGEWOOD RD
POCATELLO ID
83201-7704
US

IV. Provider business mailing address

3690 RIDGEWOOD RD
POCATELLO ID
83201-7704
US

V. Phone/Fax

Practice location:
  • Phone: 208-339-4355
  • Fax:
Mailing address:
  • Phone: 208-339-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberP-64
License Number StateID

VIII. Authorized Official

Name: DR. DON GILBERT
Title or Position: OWNER
Credential:
Phone: 208-339-4355