Provider Demographics
NPI:1538648951
Name:REYES, ANDREW ROBERT
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROBERT
Last Name:REYES
Suffix:
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 1:6612 TERREBONNE CT
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-7733
Mailing Address - Country:US
Mailing Address - Phone:661-670-1138
Mailing Address - Fax:
Practice Address - Street 1:6612 TERREBONNE CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-7733
Practice Address - Country:US
Practice Address - Phone:661-670-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA999034367Medicaid