Healthcare Provider Details

I. General information

NPI: 1659195857
Provider Name (Legal Business Name): RADISH NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S 11TH ST STE 4B
COEUR D ALENE ID
83814-4000
US

IV. Provider business mailing address

2915 E FERNAN CT
COEUR D ALENE ID
83814-5803
US

V. Phone/Fax

Practice location:
  • Phone: 925-818-9399
  • Fax:
Mailing address:
  • Phone: 925-818-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MEGHAN KONEGNI
Title or Position: OWNER
Credential: MS, RD, CSR, LD
Phone: 925-818-9399