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General NPI Number Information
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NPI Number | 1528247905
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Entity Type | Organization
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Legal Business Name | REDLAND CLINIC LLC
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Dates
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Enumeration Date | 11/01/2007
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 740 US HIGHWAY 231
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City | WETUMPKA
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State | AL
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Zip | 36093-1228
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Country | US
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Telephone | 334-567-8932
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Fax | 334-567-8933
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Provider Business Mailing Address
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Address Line | PO BOX 399
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City | WETUMPKA
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State | AL
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Zip | 36092-0007
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Country | US
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Telephone | 334-567-8932
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Fax | 334-567-8933
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL BANTILAN MATELA
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Credential | M.D.
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Telephone | 334-354-9219
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 27101
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License Number State | AL
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