1104379429 NPI number — AUDREY MONIQUE REYES SESE PT DPT

Table of content: AUDREY MONIQUE REYES SESE PT DPT (NPI 1104379429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104379429 NPI number — AUDREY MONIQUE REYES SESE PT DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SESE
Provider First Name:
AUDREY
Provider Middle Name:
MONIQUE REYES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT DPT
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:
1104379429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10226 KERNWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTA LOMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91737-3034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-200-5807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16008 KAMANA RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-1376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-810-7767
Provider Business Practice Location Address Fax Number:
760-810-7769
Provider Enumeration Date:
08/03/2016

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: 225100000X , with the licence number:  43410 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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