Provider Demographics
NPI:1700602364
Name:RADIANT PRIME
Entity type:Organization
Organization Name:RADIANT PRIME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER & CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MCGLONE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-384-8050
Mailing Address - Street 1:4948 REFLECTING POND CIR
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-4064
Mailing Address - Country:US
Mailing Address - Phone:813-384-8050
Mailing Address - Fax:813-336-8804
Practice Address - Street 1:7075 WADES MILL RD
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-8293
Practice Address - Country:US
Practice Address - Phone:813-384-8050
Practice Address - Fax:813-336-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-28
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty