=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366794299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SNAKE RIVER EYE ASSOCIATES OF SHELLEY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2012
-----------------------------------------------------
Last Update Date | 11/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 357 W FIR ST
-----------------------------------------------------
City | SHELLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83274-1456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-881-5145
-----------------------------------------------------
Fax | 208-881-5146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX K
-----------------------------------------------------
City | SHELLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83274-0910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-881-5145
-----------------------------------------------------
Fax | 208-881-5146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DENNIS RADFORD
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 208-881-5145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------