Provider Demographics
NPI:1619132198
Name:REYES, EUGENIO FAJARDO
Entity Type:Individual
Prefix:MR
First Name:EUGENIO
Middle Name:FAJARDO
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GENE
Other - Middle Name:F
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3261 W SARGENT RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9212
Mailing Address - Country:US
Mailing Address - Phone:925-963-7957
Mailing Address - Fax:209-369-7010
Practice Address - Street 1:3261 W SARGENT RD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-9212
Practice Address - Country:US
Practice Address - Phone:925-963-7957
Practice Address - Fax:209-369-7010
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities