Provider Demographics
NPI:1225659709
Name:REYNOLDS, ROGER WAYNE SR (NEMT PROVIDER)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WAYNE
Last Name:REYNOLDS
Suffix:SR
Gender:M
Credentials:NEMT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14531 DOUGLAS LN
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-4827
Mailing Address - Country:US
Mailing Address - Phone:276-477-0997
Mailing Address - Fax:
Practice Address - Street 1:14531 DOUGLAS LN
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-4827
Practice Address - Country:US
Practice Address - Phone:276-477-0997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62326452172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT62326452OtherDRIVERS LICENSE