1811049489 NPI number — MS. THERESE REYNOLDS LHMC

Table of content: MS. THERESE REYNOLDS LHMC (NPI 1811049489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811049489 NPI number — MS. THERESE REYNOLDS LHMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
THERESE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LHMC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811049489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3949 EVANS AVE STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-9341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-764-0444
Provider Business Mailing Address Fax Number:
941-761-0774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3390 TAMIAMI TRL STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-8161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-764-0444
Provider Business Practice Location Address Fax Number:
941-761-0774
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH0004312 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 013067500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com