Provider Demographics
NPI:1790140473
Name:REYNOLDS, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:REYNOLDS
Suffix:
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 1:819 TARENTO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2825
Mailing Address - Country:US
Mailing Address - Phone:800-330-7711
Mailing Address - Fax:
Practice Address - Street 1:819 TARENTO DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2825
Practice Address - Country:US
Practice Address - Phone:800-330-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist