Provider Demographics
NPI:1740759083
Name:REYES, ANTONIO JR
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:REYES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 E REGENT ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1415
Mailing Address - Country:US
Mailing Address - Phone:310-674-9179
Mailing Address - Fax:310-674-0120
Practice Address - Street 1:660 E REGENT ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1415
Practice Address - Country:US
Practice Address - Phone:310-674-9179
Practice Address - Fax:310-674-0120
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA900676339OtherIRS