MEDICARE: REDICLINIC OF MD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1356728984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REDICLINIC OF MD, LLC

Provider Business Mailing Address
First Line	:	9 GREENWAY PLZ
Second Line	:	STE. 2950
City	:	HOUSTON
State	:	TX
Zip	:	77046-0905
Country	:	US
Telephone Number	:	713-335-1754
Fax Number	:	713-358-4870

Provider Business Practice Location Address
First Line	:	8601 BALTIMORE NATIONAL PIKE
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-4176
Country	:	US
Telephone Number	:	713-335-1742
Fax Number	:	713-358-4881

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	DANIELLE BARRERA
Credential	:
Telephone Number	:	713-580-9489

Provider Enumeration Date	:	05/04/2015
Last Update Date	:	05/04/2015

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