Provider Demographics
NPI:1285454009
Name:RADIANT MEDICAL CLINIC OF EAST TEXAS LLC
Entity type:Organization
Organization Name:RADIANT MEDICAL CLINIC OF EAST TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOSEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:903-343-7480
Mailing Address - Street 1:3613 ROCK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-1635
Mailing Address - Country:US
Mailing Address - Phone:903-343-7480
Mailing Address - Fax:
Practice Address - Street 1:3613 ROCK CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-1635
Practice Address - Country:US
Practice Address - Phone:903-343-7480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIANT MEDICAL CLINIC OF EAST TEXAS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty