Provider Demographics
NPI:1003338526
Name:MEDINA, RAYNOLD
Entity Type:Individual
Prefix:
First Name:RAYNOLD
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E 1ST AVE APT 1207
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4961
Mailing Address - Country:US
Mailing Address - Phone:786-303-7782
Mailing Address - Fax:
Practice Address - Street 1:150 E 1ST AVE APT 1207
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4961
Practice Address - Country:US
Practice Address - Phone:786-303-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty