Provider Demographics
NPI:1144057852
Name:RIVER HORSE MEDICAL CLINIC
Entity type:Organization
Organization Name:RIVER HORSE MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-792-1011
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0225
Mailing Address - Country:US
Mailing Address - Phone:208-792-1011
Mailing Address - Fax:208-616-1453
Practice Address - Street 1:222 SOUTHWAY AVE STE C
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2703
Practice Address - Country:US
Practice Address - Phone:208-792-1011
Practice Address - Fax:208-616-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-17
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396151395OtherPROVIDER NPI