Healthcare Provider Details

I. General information

NPI: 1710511621
Provider Name (Legal Business Name): RAYDIANT WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2020
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 37TH ST NE STE 500
ROCHESTER MN
55906-5464
US

IV. Provider business mailing address

6674 ZUMBRO HYLANDS NW
ROCHESTER MN
55901-8516
US

V. Phone/Fax

Practice location:
  • Phone: 507-242-8746
  • Fax: 507-204-2117
Mailing address:
  • Phone: 513-515-1727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MALIA RAY
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 513-515-1727