Healthcare Provider Details

I. General information

NPI: 1104137074
Provider Name (Legal Business Name): SNAKE RIVER PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E. BROADWAY SUITE 212
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 2862
JACKSON WY
83001-2862
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-6077
  • Fax:
Mailing address:
  • Phone: 307-733-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2735A
License Number StateWY

VIII. Authorized Official

Name: DR. MICHAEL BARRY GELLIS
Title or Position: MEMBER
Credential: MD
Phone: 307-733-6077