Provider Demographics
NPI:1659449221
Name:REYES, EDMOND CHAN (INDEPENDENT CORPSMAN)
Entity Type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:CHAN
Last Name:REYES
Suffix:
Gender:M
Credentials:INDEPENDENT CORPSMAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35755 CORAL DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596
Mailing Address - Country:US
Mailing Address - Phone:951-852-8530
Mailing Address - Fax:619-767-1497
Practice Address - Street 1:NAVAL AIR STATION NORTH ISLAND
Practice Address - Street 2:BLDG 290
Practice Address - City:SANDIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135
Practice Address - Country:US
Practice Address - Phone:619-767-1496
Practice Address - Fax:619-767-1497
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider