Healthcare Provider Details

I. General information

NPI: 1548752918
Provider Name (Legal Business Name): SNAKE RIVER ADULT MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 5TH ST
CLARKSTON WA
99403-3001
US

IV. Provider business mailing address

725 DIAGONAL ST
CLARKSTON WA
99403-2043
US

V. Phone/Fax

Practice location:
  • Phone: 509-295-8398
  • Fax: 509-295-8416
Mailing address:
  • Phone: 509-295-8398
  • Fax: 509-295-8416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number604282863
License Number StateWA

VIII. Authorized Official

Name: BRIAN FRANCIS CIEZKI
Title or Position: OWNER/OPERATOR
Credential: ACNP
Phone: 509-295-8398