Provider Demographics
NPI:1578924205
Name:REYES, ROLANDO
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:
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 1:280 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-4124
Mailing Address - Country:US
Mailing Address - Phone:510-238-5020
Mailing Address - Fax:510-352-9981
Practice Address - Street 1:280 17TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-4124
Practice Address - Country:US
Practice Address - Phone:510-238-5020
Practice Address - Fax:510-352-9981
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN269056164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1411033663OtherEMPLOYER IDENTIFICATION NUMBER