Provider Demographics
NPI:1548752918
Name:SNAKE RIVER ADULT MEDICINE LLC
Entity Type:Organization
Organization Name:SNAKE RIVER ADULT MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:CIEZKI
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP
Authorized Official - Phone:509-295-8398
Mailing Address - Street 1:725 DIAGONAL ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2043
Mailing Address - Country:US
Mailing Address - Phone:509-295-8398
Mailing Address - Fax:509-295-8416
Practice Address - Street 1:1625 5TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-3001
Practice Address - Country:US
Practice Address - Phone:509-295-8398
Practice Address - Fax:509-295-8416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-01
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604282863261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care