Provider Demographics
NPI:1861972853
Name:RADDON LLC
Entity type:Organization
Organization Name:RADDON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:N
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-335-9797
Mailing Address - Street 1:114 GATEWAY CORPORATE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9785
Mailing Address - Country:US
Mailing Address - Phone:770-335-9797
Mailing Address - Fax:
Practice Address - Street 1:114 GATEWAY CORPORATE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9785
Practice Address - Country:US
Practice Address - Phone:770-335-9797
Practice Address - Fax:803-849-8247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-18
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center