1487086195 NPI number — IAN ALLAN REYNOLDS BOCP

Table of content: IAN ALLAN REYNOLDS BOCP (NPI 1487086195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487086195 NPI number — IAN ALLAN REYNOLDS BOCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
IAN
Provider Middle Name:
ALLAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BOCP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REYNOLDS
Provider Other First Name:
IAN
Provider Other Middle Name:
ALLAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BOCP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487086195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
796 7TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDWOOD CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94063-3921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-335-5068
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
463 BREWSTER AVE
Provider Second Line Business Practice Location Address:
#6
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063-1785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-368-9597
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2013

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: 224P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C51219 . This is a "BOC CERTIFICATION NUMBER" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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