Provider Demographics
NPI:1811215239
Name:REGIS, REGINALD MARK
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:MARK
Last Name:REGIS
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 1:646 RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1849
Mailing Address - Country:US
Mailing Address - Phone:347-758-2904
Mailing Address - Fax:
Practice Address - Street 1:9715 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2250
Practice Address - Country:US
Practice Address - Phone:718-459-5592
Practice Address - Fax:718-459-6047
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295491164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse