Provider Demographics
NPI:1174253207
Name:REYES, BLANCA SARAI
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:SARAI
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17096 CHICO DR
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-7442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21801 CACTUS AVE STE A
Practice Address - Street 2:
Practice Address - City:MARCH AIR RESERVE BASE
Practice Address - State:CA
Practice Address - Zip Code:92518-3020
Practice Address - Country:US
Practice Address - Phone:951-529-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679041495Medicaid