Healthcare Provider Details

I. General information

NPI: 1083524813
Provider Name (Legal Business Name): RADIANT LANE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 S DIXIE HWY W APT 308
POMPANO BEACH FL
33060-8076
US

IV. Provider business mailing address

1207 S DIXIE HWY W APT 308
POMPANO BEACH FL
33060-8076
US

V. Phone/Fax

Practice location:
  • Phone: 561-222-0213
  • Fax:
Mailing address:
  • Phone: 561-222-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TELLIS THOMPSON
Title or Position: MANAGER
Credential:
Phone: 561-222-0213