Provider Demographics
NPI:1407139249
Name:REYES, PEGGY
Entity Type:Individual
Prefix:MS
First Name:PEGGY
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 1:933 BRADBURY DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:2001-B CENTRO FAMILIAR SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105
Practice Address - Country:US
Practice Address - Phone:505-710-1207
Practice Address - Fax:505-873-5970
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45172871Medicaid