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NPI Code Detail

MEDICARE: REDICLINIC OF PA, LLC

MEDICARE: REDICLINIC OF PA, 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
1261Q00000XClinic/Center

General Provider Information

NPI Number : 1770985400
Entity Type Code : Organization
Provider Name (Legal Business Name) : REDICLINIC OF PA, LLC
Provider Business Mailing Address
First Line : 9 GREENWAY PLZ
Second Line : STE. 2950
City : HOUSTON
State : TX
Zip : 77046-0905
Country : US
Telephone Number : 713-335-1754
Fax Number :
Provider Business Practice Location Address
First Line : 510 E BALTIMORE PIKE
Second Line :
City : MEDIA
State : PA
Zip : 19063-3836
Country : US
Telephone Number : 713-335-1754
Fax Number :
Authorized Official
Title or Position : CHIEF OPERATING OFFICER
Name : DANIELLE BARRERA
Credential :
Telephone Number : 713-335-1754
Provider Enumeration Date : 09/25/2014
Last Update Date : 09/25/2014

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