1467407452 NPI number — REGINA MARIE REUILLON MSPT

Table of content: REGINA MARIE REUILLON MSPT (NPI 1467407452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467407452 NPI number — REGINA MARIE REUILLON MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REUILLON
Provider First Name:
REGINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RICCI
Provider Other First Name:
REGINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467407452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4287 SE FEDERAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34997-4936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-223-3440
Provider Business Mailing Address Fax Number:
772-221-3373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4287 SE FEDERAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34997-4936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-223-3440
Provider Business Practice Location Address Fax Number:
772-221-3373
Provider Enumeration Date:
05/24/2006

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:  PT12992 , 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: Y7677 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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