Provider Demographics
NPI:1558445890
Name:REIDA, PATRICK DAVID (DC)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:DAVID
Last Name:REIDA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:PATRICK
Other - Middle Name:DAVID
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:603 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2523
Mailing Address - Country:US
Mailing Address - Phone:310-514-0777
Mailing Address - Fax:310-514-2777
Practice Address - Street 1:603 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2523
Practice Address - Country:US
Practice Address - Phone:310-514-0777
Practice Address - Fax:310-514-2777
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC24249Medicare ID - Type Unspecified