Provider Demographics
NPI:1528247905
Name:REDLAND CLINIC LLC
Entity type:Organization
Organization Name:REDLAND CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BANTILAN
Authorized Official - Last Name:MATELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-354-9219
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0007
Mailing Address - Country:US
Mailing Address - Phone:334-567-8932
Mailing Address - Fax:334-567-8933
Practice Address - Street 1:740 US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36093-1228
Practice Address - Country:US
Practice Address - Phone:334-567-8932
Practice Address - Fax:334-567-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty