MEDICARE: REDICLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1225156870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REDICLINIC LLC

Provider Business Mailing Address
First Line	:	18059 CRESCENT ROYALE WAY
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-3467
Country	:	US
Telephone Number	:	713-935-0333
Fax Number	:	713-935-9353

Provider Business Practice Location Address
First Line	:	11750 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-2516
Country	:	US
Telephone Number	:	866-935-0333
Fax Number	:	713-935-9353

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MR. RICK VAN PELT
Credential	:
Telephone Number	:	866-932-0333

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	08/22/2020

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Directions to “REDICLINIC LLC ” Practice Location

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