Provider Demographics
NPI:1104912740
Name:SNAKE RIVER EAR, NOSE & THROAT PC
Entity type:Organization
Organization Name:SNAKE RIVER EAR, NOSE & THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:KACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-735-1000
Mailing Address - Street 1:706 NORTH COLLEGE ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-735-1000
Mailing Address - Fax:208-732-5345
Practice Address - Street 1:706 NORTH COLLEGE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-735-1000
Practice Address - Fax:208-732-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDA89785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805168100Medicaid
ID805168100Medicaid
ID=========OtherTAX ID
ID805168100Medicaid
IDA51210Medicare UPIN