1619070208 NPI number — SNAKE RIVER RADIOLOGY PC

Table of content: (NPI 1619070208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619070208 NPI number — SNAKE RIVER RADIOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNAKE RIVER RADIOLOGY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619070208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
964 W IDAHO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97914-2111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-889-9545
Provider Business Mailing Address Fax Number:
541-889-8376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
964 W IDAHO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97914-2111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-889-9545
Provider Business Practice Location Address Fax Number:
541-889-8376
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CEGNAR
Authorized Official First Name:
JANET
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CORP SECRETARY
Authorized Official Telephone Number:
541-889-9545

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 80408077 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 084934 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com