Provider Demographics
NPI:1366794299
Name:SNAKE RIVER EYE ASSOCIATES OF SHELLEY, PLLC
Entity type:Organization
Organization Name:SNAKE RIVER EYE ASSOCIATES OF SHELLEY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-881-5145
Mailing Address - Street 1:PO BOX K
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-0910
Mailing Address - Country:US
Mailing Address - Phone:208-881-5145
Mailing Address - Fax:208-881-5146
Practice Address - Street 1:357 W FIR ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1456
Practice Address - Country:US
Practice Address - Phone:208-881-5145
Practice Address - Fax:208-881-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1366794299Medicaid
ID1366794299Medicaid
ID20002099Medicare PIN