Provider Demographics
NPI:1558679662
Name:REDICLINIC AUSTIN, LLC
Entity Type:Organization
Organization Name:REDICLINIC AUSTIN, LLC
Other - Org Name:REDICLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-580-9489
Mailing Address - Street 1:9 GREENWAY PLZ
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 CANYON RIDGE DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-1632
Practice Address - Country:US
Practice Address - Phone:512-836-9000
Practice Address - Fax:512-836-9003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REDICLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-23
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y412Medicare PIN