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1104137074 NPI number — SNAKE RIVER PLASTIC SURGERY LLC

NPI Number: 1104137074
Health Care Provider/Practitioner: SNAKE RIVER PLASTIC SURGERY LLC

Information about “1104137074” NPI (SNAKE RIVER PLASTIC SURGERY LLC) exists in 1104137074 in HTML format HTML  |  1104137074 in plain Text format TXT  |  1104137074 in PDF (Portable Document Format) PDF  |  1104137074 in an XML format XML  formats.

NPI Number : 1104137074 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1104137074",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "SNAKE RIVER PLASTIC SURGERY LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 2862",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "JACKSON",
    "MailingAddressStateName": "WY",
    "MailingAddressPostalCode": "83001-2862",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "307-733-6077",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "555 E. BROADWAY",
    "SecondLinePracticeLocationAddress": "SUITE 212",
    "PracticeLocationAddressCityName": "JACKSON",
    "PracticeLocationAddressStateName": "WY",
    "PracticeLocationAddressPostalCode": "83001",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "307-733-6077",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "06/25/2010",
    "LastUpdateDate": "06/25/2010",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "GELLIS",
    "AuthorizedOfficialFirstName": "MICHAEL",
    "AuthorizedOfficialMiddleName": "BARRY",
    "AuthorizedOfficialTitle": "MEMBER",
    "AuthorizedOfficialNamePrefix": "DR.",
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "MD",
    "AuthorizedOfficialTelephoneNumber": "307-733-6077",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "174400000X",
        "TaxonomyName": "Specialist",
        "LicenseNumber": "2735A",
        "LicenseNumberStateCode": "WY",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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