Healthcare Provider Details

I. General information

NPI: 1326878554
Provider Name (Legal Business Name): VALLEY RADIATION PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 6TH ST
LEWISTON ID
83501-2439
US

IV. Provider business mailing address

PO BOX 239
LEWISTON ID
83501-0239
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-5600
  • Fax: 530-799-5755
Mailing address:
  • Phone: 208-799-5600
  • Fax: 208-799-5755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT KENNETH FAIRBANKS
Title or Position: SOLE MEMBER
Credential: MD
Phone: 509-993-7197