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General NPI Number Information
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NPI Number | 1285454009
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Entity Type | Organization
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Legal Business Name | RADIANT MEDICAL CLINIC OF EAST TEXAS LLC
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Dates
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Enumeration Date | 10/16/2024
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 3613 ROCK CREEK DR
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City | TYLER
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State | TX
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Zip | 75707-1635
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Country | US
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Telephone | 903-343-7480
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Fax |
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Provider Business Mailing Address
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Address Line | 3613 ROCK CREEK DR
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City | TYLER
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State | TX
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Zip | 75707-1635
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Country | US
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Telephone | 903-343-7480
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. DORIS UDOSEN
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Credential | APRN
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Telephone | 903-343-7480
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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