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General NPI Number Information
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NPI Number | 1104912740
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Entity Type | Organization
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Legal Business Name | SNAKE RIVER EAR, NOSE & THROAT PC
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 01/15/2013
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Provider Practice Location Address
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Address Line | 706 NORTH COLLEGE ROAD SUITE C
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City | TWIN FALLS
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State | ID
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Zip | 83301
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Country | US
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Telephone | 208-735-1000
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Fax | 208-732-5345
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Provider Business Mailing Address
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Address Line | 706 NORTH COLLEGE ROAD SUITE C
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City | TWIN FALLS
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State | ID
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Zip | 83301
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Country | US
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Telephone | 208-735-1000
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Fax | 208-732-5345
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Authorized Official
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Title or Position | OWNER
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Name | ROD KACK
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Credential | MD
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Telephone | 208-735-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A89785
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License Number State | ID
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