Provider Demographics
NPI:1972911725
Name:REALISTIC MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:REALISTIC MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-434-5877
Mailing Address - Street 1:2646 SOUTH LOOP WEST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054
Mailing Address - Country:US
Mailing Address - Phone:713-434-5877
Mailing Address - Fax:832-834-7539
Practice Address - Street 1:2646 S LOOP W
Practice Address - Street 2:SUITE 520
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2665
Practice Address - Country:US
Practice Address - Phone:713-434-5877
Practice Address - Fax:832-834-7539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty