Provider Demographics
NPI:1730699216
Name:RELIANCE INTERNATIONAL CLINIC, LLC
Entity type:Organization
Organization Name:RELIANCE INTERNATIONAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-623-1816
Mailing Address - Street 1:4040 MCDERMOTT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7735
Mailing Address - Country:US
Mailing Address - Phone:469-552-5988
Mailing Address - Fax:972-668-1618
Practice Address - Street 1:4040 MCDERMOTT RD STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-7735
Practice Address - Country:US
Practice Address - Phone:469-552-5988
Practice Address - Fax:972-668-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0391435-02Medicaid