=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760119986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRECISION FAMILY MEDICINE & AESTHETICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2022
-----------------------------------------------------
Last Update Date | 10/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 S WOODRUFF AVE STE 11
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-757-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 S WOODRUFF AVE STE 11
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRADLEY RADFORD
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 208-419-3271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------