Provider Demographics
NPI:1629261375
Name:CHAVEZ, REYNA R
Entity Type:Individual
Prefix:
First Name:REYNA
Middle Name:R
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 S STATE COLLEGE BLVD
Mailing Address - Street 2:SUITE 3-K
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5724
Mailing Address - Country:US
Mailing Address - Phone:714-758-0660
Mailing Address - Fax:714-758-0770
Practice Address - Street 1:1440 S STATE COLLEGE BLVD
Practice Address - Street 2:SUITE 3-K
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5724
Practice Address - Country:US
Practice Address - Phone:714-758-0660
Practice Address - Fax:714-758-0770
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFAC336252085R0202X
CA261QR0207X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA236328OtherMEDICARE NORTHERN CALIFORNIA X-RAY PTAN
CACA268381OtherMEDICARE NORTHERN CALIFORNIA MAMMOGRAPHY PTAN
CACB276312OtherMEDICARE LA COUNTY MAMMOGRAPHY PTAN
CACB284412OtherMEDICARE SOUTHERN CALIFORNIA MAMMOGRAPHY PTAN
CAP01543590OtherRAILROAD MEDICARE PTAN
CACB207156OtherMEDICARE SOUTHERN CALIFORNIA X-RAY PTAN