Healthcare Provider Details

I. General information

NPI: 1467274944
Provider Name (Legal Business Name): SNAKE RIVER WOUND CARE AND HYPERBARICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 NORTH COLLEGE ROAD
TWIN FALLS ID
83301
US

IV. Provider business mailing address

781 NORTH COLLEGE ROAD
TWIN FALLS ID
83301
US

V. Phone/Fax

Practice location:
  • Phone: 210-255-7565
  • Fax:
Mailing address:
  • Phone: 210-255-7565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SUMEDHA MOHAN
Title or Position: OWNER
Credential:
Phone: 210-255-7565