Provider Demographics
NPI:1124193040
Name:SNAKE RIVER MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:SNAKE RIVER MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:CRT, RPSGT
Authorized Official - Phone:208-735-2252
Mailing Address - Street 1:526 SHOUP AVE W STE B
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5050
Mailing Address - Country:US
Mailing Address - Phone:208-735-2252
Mailing Address - Fax:208-735-3917
Practice Address - Street 1:526 SHOUP AVE W STE B
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-735-2252
Practice Address - Fax:208-735-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME249332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807127500Medicaid
ID807127500Medicaid