Healthcare Provider Details

I. General information

NPI: 1104912740
Provider Name (Legal Business Name): SNAKE RIVER EAR, NOSE & THROAT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 NORTH COLLEGE ROAD SUITE C
TWIN FALLS ID
83301
US

IV. Provider business mailing address

706 NORTH COLLEGE ROAD SUITE C
TWIN FALLS ID
83301
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-1000
  • Fax: 208-732-5345
Mailing address:
  • Phone: 208-735-1000
  • Fax: 208-732-5345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA89785
License Number StateID

VIII. Authorized Official

Name: ROD KACK
Title or Position: OWNER
Credential: MD
Phone: 208-735-1000