Provider Demographics
NPI:1326729039
Name:REYES, ELISAMA
Entity Type:Individual
Prefix:MISS
First Name:ELISAMA
Middle Name:
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 1:1120 W LA VETA AVE STE 660&470
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4231
Mailing Address - Country:US
Mailing Address - Phone:657-767-2719
Mailing Address - Fax:
Practice Address - Street 1:1120 W LA VETA AVE STE 660&470
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4231
Practice Address - Country:US
Practice Address - Phone:657-767-2719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker