Provider Demographics
NPI:1588038616
Name:CARMEN HERNANDEZ RADFORD
Entity Type:Organization
Organization Name:CARMEN HERNANDEZ RADFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:HERNANDEZ
Authorized Official - Last Name:RADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-757-1854
Mailing Address - Street 1:5451 THATCHER AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4935
Mailing Address - Country:US
Mailing Address - Phone:208-757-1854
Mailing Address - Fax:
Practice Address - Street 1:3652 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-419-0593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1660A251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare