Provider Demographics
NPI:1598739112
Name:REYNOLDS, WM RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:WM
Middle Name:RYAN
Last Name:REYNOLDS
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 1:8150 MOORSBRIDGE RD STE B
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7419
Mailing Address - Country:US
Mailing Address - Phone:269-343-2667
Mailing Address - Fax:
Practice Address - Street 1:8150 MOORSBRIDGE RD STE B
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7419
Practice Address - Country:US
Practice Address - Phone:269-343-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009081111N00000X
MIWR009081111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4962083Medicaid
MI4962083Medicaid