Provider Demographics
NPI:1114003472
Name:DR L REYNOLDS ASSOCIATES PC
Entity Type:Organization
Organization Name:DR L REYNOLDS ASSOCIATES PC
Other - Org Name:REYNOLDS, L ASSOC PC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-353-1280
Mailing Address - Street 1:24500 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2414
Mailing Address - Country:US
Mailing Address - Phone:248-353-1280
Mailing Address - Fax:248-353-6193
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:248-353-1280
Practice Address - Fax:248-353-6193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid
MI=========Medicaid