Provider Demographics
NPI:1710511621
Name:RAYDIANT WELLNESS LLC
Entity Type:Organization
Organization Name:RAYDIANT WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-515-1727
Mailing Address - Street 1:6674 ZUMBRO HYLANDS NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-8516
Mailing Address - Country:US
Mailing Address - Phone:513-515-1727
Mailing Address - Fax:
Practice Address - Street 1:275 37TH ST NE STE 500
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-5464
Practice Address - Country:US
Practice Address - Phone:507-242-8746
Practice Address - Fax:507-204-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-29
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty