Healthcare Provider Details

I. General information

NPI: 1730126566
Provider Name (Legal Business Name): SNAKE RIVER UROLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 SHOSHONE ST E SUITE 201
TWIN FALLS ID
83301-6110
US

IV. Provider business mailing address

660 SHOSHONE ST E SUITE 201
TWIN FALLS ID
83301-6110
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-3040
  • Fax: 208-732-3195
Mailing address:
  • Phone: 208-732-3040
  • Fax: 208-732-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID BOWYER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 208-732-3040