1588266654 NPI number — MRS. AMANDA PAIGE REAVES RD

Table of content: MRS. AMANDA PAIGE REAVES RD (NPI 1588266654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588266654 NPI number — MRS. AMANDA PAIGE REAVES RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REAVES
Provider First Name:
AMANDA
Provider Middle Name:
PAIGE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANSBACH
Provider Other First Name:
AMANDA
Provider Other Middle Name:
PAIGE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588266654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17751 PAPA BEAR CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89508-5826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-391-4650
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 MILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-466-0592
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2020

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: 133V00000X , with the licence number:  39779-DI-0 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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