Provider Demographics
NPI:1497873723
Name:REDICLINIC LLC
Entity Type:Organization
Organization Name:REDICLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOURNET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-580-9468
Mailing Address - Street 1:9 GREENWAY PLAZA
Mailing Address - Street 2:STE 2950
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0905
Mailing Address - Country:US
Mailing Address - Phone:713-935-0333
Mailing Address - Fax:713-935-9353
Practice Address - Street 1:16900 N. FM 620
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664
Practice Address - Country:US
Practice Address - Phone:512-687-0561
Practice Address - Fax:713-935-9353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y095Medicare PIN