Healthcare Provider Details

I. General information

NPI: 1891178885
Provider Name (Legal Business Name): SNAKE RIVER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SW 3RD AVE STE 3200
ONTARIO OR
97914-4560
US

IV. Provider business mailing address

1050 SW 3RD AVE STE 3200
ONTARIO OR
97914-4560
US

V. Phone/Fax

Practice location:
  • Phone: 541-881-2380
  • Fax: 541-881-2389
Mailing address:
  • Phone: 541-881-2380
  • Fax: 541-881-2389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA000573
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberPA000573
License Number StateOR

VIII. Authorized Official

Name: STEPHEN K AMES
Title or Position: PRESIDENT
Credential: MD
Phone: 541-881-2380