Provider Demographics
NPI:1093178634
Name:MCREYNOLDS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MCREYNOLDS
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 1:300 W BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2363
Mailing Address - Country:US
Mailing Address - Phone:708-579-2338
Mailing Address - Fax:
Practice Address - Street 1:300 W BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2363
Practice Address - Country:US
Practice Address - Phone:708-579-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILP000386342146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic