Provider Demographics
NPI:1346764511
Name:BOARDMAN, RICHARD DALLIN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DALLIN
Last Name:BOARDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:208-297-7019
Mailing Address - Fax:
Practice Address - Street 1:810 S 100 W STE A
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6093
Practice Address - Country:US
Practice Address - Phone:435-787-7200
Practice Address - Fax:435-787-7203
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDODP-100444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program