1982247318 NPI number — TARYN REYNOLDS

Table of content: TARYN REYNOLDS (NPI 1982247318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982247318 NPI number — TARYN REYNOLDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
TARYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1982247318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 JEFFERSON ST STE 2C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24504-1724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-229-6194
Provider Business Mailing Address Fax Number:
617-807-0958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
463 WORCESTER RD STE 406
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRAMINGHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01701-5354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-395-5806
Provider Business Practice Location Address Fax Number:
617-807-0958
Provider Enumeration Date:
10/17/2019

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: 101YP2500X , with the licence number:  11106 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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