Provider Demographics
NPI:1114551504
Name:REECE, TEDDY CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:CHRISTOPHER
Last Name:REECE
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 1:4615 UTAH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3177
Mailing Address - Country:US
Mailing Address - Phone:619-540-8342
Mailing Address - Fax:
Practice Address - Street 1:717 ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2013
Practice Address - Country:US
Practice Address - Phone:619-435-3214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD8574116OtherDRIVER LICENSE