Provider Demographics
NPI:1629264403
Name:REA, TERESA N/A (N/A)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:N/A
Last Name:REA
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-0727
Mailing Address - Country:US
Mailing Address - Phone:805-929-4891
Mailing Address - Fax:
Practice Address - Street 1:813 ROSANA PLACE
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-5605
Practice Address - Country:US
Practice Address - Phone:805-929-4891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40030343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)