Provider Demographics
NPI:1346679990
Name:REYNOLDS, CHARLES EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:REYNOLDS
Suffix:JR
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 1:3514 CLEARBROOK ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-5547
Mailing Address - Country:US
Mailing Address - Phone:901-362-6015
Mailing Address - Fax:901-404-5106
Practice Address - Street 1:3514 CLEARBROOK ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-5547
Practice Address - Country:US
Practice Address - Phone:901-362-6015
Practice Address - Fax:901-404-5106
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN113004427251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1346679990Medicare Oscar/Certification