Healthcare Provider Details

I. General information

NPI: 1366794299
Provider Name (Legal Business Name): SNAKE RIVER EYE ASSOCIATES OF SHELLEY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 W FIR ST
SHELLEY ID
83274-1456
US

IV. Provider business mailing address

PO BOX K
SHELLEY ID
83274-0910
US

V. Phone/Fax

Practice location:
  • Phone: 208-881-5145
  • Fax: 208-881-5146
Mailing address:
  • Phone: 208-881-5145
  • Fax: 208-881-5146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateID

VIII. Authorized Official

Name: DENNIS RADFORD
Title or Position: OWNER
Credential: OD
Phone: 208-881-5145