Provider Demographics
NPI:1831555143
Name:RADIANT
Entity type:Organization
Organization Name:RADIANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:304-687-4204
Mailing Address - Street 1:2301 TERRA CROSSING BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-3909
Mailing Address - Country:US
Mailing Address - Phone:502-410-0191
Mailing Address - Fax:502-890-5177
Practice Address - Street 1:2301 TERRA CROSSING BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4994
Practice Address - Country:US
Practice Address - Phone:304-687-4204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1075363A00000X
KY3007017363LF0000X
KY22964208D00000X
KY5059111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty