Provider Demographics
NPI:1538476569
Name:REYES, JOHNNY (EMT)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 CHERRY AVE APT 274
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2743
Mailing Address - Country:US
Mailing Address - Phone:408-661-8338
Mailing Address - Fax:
Practice Address - Street 1:4951 CHERRY AVE APT 274
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-2743
Practice Address - Country:US
Practice Address - Phone:408-661-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5540761172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver