Healthcare Provider Details

I. General information

NPI: 1669410361
Provider Name (Legal Business Name): SNAKE RIVER GASTROENTEROLOGY LABS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MORRISON ST
TWIN FALLS ID
83301-5451
US

IV. Provider business mailing address

141 MORRISON ST
TWIN FALLS ID
83301-5451
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-3030
  • Fax: 208-733-8970
Mailing address:
  • Phone: 208-732-3030
  • Fax: 208-733-8970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT WARD
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 208-732-3030