Provider Demographics
NPI:1669410361
Name:SNAKE RIVER GASTROENTEROLOGY LABS, L.L.C.
Entity type:Organization
Organization Name:SNAKE RIVER GASTROENTEROLOGY LABS, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-732-3030
Mailing Address - Street 1:141 MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5451
Mailing Address - Country:US
Mailing Address - Phone:208-732-3030
Mailing Address - Fax:208-733-8970
Practice Address - Street 1:141 MORRISON ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5451
Practice Address - Country:US
Practice Address - Phone:208-732-3030
Practice Address - Fax:208-733-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806686500Medicaid
IDP00056475OtherRR MEDICARE
ID806686500Medicaid