Provider Demographics
NPI:1437219052
Name:REYES, PHILLIP C (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:C
Last Name:REYES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2059 CLINTON AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4379
Mailing Address - Country:US
Mailing Address - Phone:510-865-1355
Mailing Address - Fax:510-764-4912
Practice Address - Street 1:2059 CLINTON AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4379
Practice Address - Country:US
Practice Address - Phone:510-865-1355
Practice Address - Fax:510-764-4912
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 19954111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0199540Medicare UPIN