Healthcare Provider Details

I. General information

NPI: 1619070208
Provider Name (Legal Business Name): SNAKE RIVER RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

964 W IDAHO AVE
ONTARIO OR
97914-2111
US

IV. Provider business mailing address

964 W IDAHO AVE
ONTARIO OR
97914-2111
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-9545
  • Fax: 541-889-8376
Mailing address:
  • Phone: 541-889-9545
  • Fax: 541-889-8376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANET R CEGNAR
Title or Position: CORP SECRETARY
Credential: MD
Phone: 541-889-9545