Healthcare Provider Details

I. General information

NPI: 1790140903
Provider Name (Legal Business Name): REDICLINIC OF VA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260A HUNTERS WOODS PLZ
RESTON VA
20191-2898
US

IV. Provider business mailing address

9 GREENWAY PLZ SUITE 2950
HOUSTON TX
77046-0905
US

V. Phone/Fax

Practice location:
  • Phone: 713-358-4881
  • Fax: 713-358-4881
Mailing address:
  • Phone: 713-335-1731
  • Fax: 713-574-2794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE BARRERA
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 713-580-9489