Provider Demographics
NPI:1033899380
Name:REYNOLDS, MICHAEL L
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:REYNOLDS
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 1:370 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3578
Mailing Address - Country:US
Mailing Address - Phone:318-243-4050
Mailing Address - Fax:
Practice Address - Street 1:1201 ATKINS RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-8717
Practice Address - Country:US
Practice Address - Phone:318-243-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15228253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care