Provider Demographics
NPI:1902180243
Name:RADFORD, DARRYL E SR (REVEREND)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:E
Last Name:RADFORD
Suffix:SR
Gender:M
Credentials:REVEREND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 ALBEMARLE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6654
Mailing Address - Country:US
Mailing Address - Phone:704-536-6167
Mailing Address - Fax:704-536-6515
Practice Address - Street 1:4921 ALBEMARLE RD STE 204
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6654
Practice Address - Country:US
Practice Address - Phone:704-536-6167
Practice Address - Fax:704-536-6515
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1763096172V00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator