Provider Demographics
NPI:1164035655
Name:REYNOLDS, MICHAEL JUSTIN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUSTIN
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 1:3926 SOUTHERN AVE SE APT 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-1123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3926 SOUTHERN AVE SE
Practice Address - Street 2:101
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2002
Practice Address - Country:US
Practice Address - Phone:202-378-7881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide