Provider Demographics
NPI:1154842649
Name:REYES ROMERO, VICTOR (LMT)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:REYES ROMERO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 YARDLEY CT APT 310
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4269
Mailing Address - Country:US
Mailing Address - Phone:317-201-6978
Mailing Address - Fax:
Practice Address - Street 1:1355 W 96TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1101
Practice Address - Country:US
Practice Address - Phone:317-201-6978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21304667225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist