Provider Demographics
NPI:1659853174
Name:RADIANT HEALTH LLC
Entity Type:Organization
Organization Name:RADIANT HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TANJA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:541-908-3672
Mailing Address - Street 1:350 ARAPAHOE AVE APT 18
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5843
Mailing Address - Country:US
Mailing Address - Phone:541-908-3672
Mailing Address - Fax:
Practice Address - Street 1:350 ARAPAHOE AVE APT 18
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5843
Practice Address - Country:US
Practice Address - Phone:541-908-3672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty