Provider Demographics
NPI:1619015203
Name:REYES, CARMEN LETICIA (LAC)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:LETICIA
Last Name:REYES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-4205
Mailing Address - Country:US
Mailing Address - Phone:323-257-5795
Mailing Address - Fax:
Practice Address - Street 1:1718 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1338
Practice Address - Country:US
Practice Address - Phone:323-255-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA6619171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist