Provider Demographics
NPI:1356665798
Name:SOTO, REYNALDO (LPTA)
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:SOTO
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 WOODSBORO DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-3055
Mailing Address - Country:US
Mailing Address - Phone:616-363-4239
Mailing Address - Fax:
Practice Address - Street 1:3019 COIT AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3376
Practice Address - Country:US
Practice Address - Phone:616-365-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-14
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002449225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant