Provider Demographics
NPI:1316383375
Name:EDWARDS, REGINALD CHARLES
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:CHARLES
Last Name:EDWARDS
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 1:6109 HEATHER MIST LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4232
Mailing Address - Country:US
Mailing Address - Phone:702-488-5284
Mailing Address - Fax:
Practice Address - Street 1:6109 HEATHER MIST LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4232
Practice Address - Country:US
Practice Address - Phone:702-488-5284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner