Provider Demographics
NPI:1275319998
Name:FLETCHER, REGINALD O SR
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:O
Last Name:FLETCHER
Suffix:SR
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 1:1712 WESMINSTER CIR
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-7127
Mailing Address - Country:US
Mailing Address - Phone:404-786-4222
Mailing Address - Fax:
Practice Address - Street 1:1712 WESMINSTER CIR
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-7127
Practice Address - Country:US
Practice Address - Phone:404-786-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050200552347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker