Provider Demographics
NPI:1851502256
Name:REYNAGA, CARMEN LORENIA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LORENIA
Last Name:REYNAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 W MIRACLE MILE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-3708
Mailing Address - Country:US
Mailing Address - Phone:520-750-9667
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:2424 S COTTONWOOD LN UNIT 151
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-2717
Practice Address - Country:US
Practice Address - Phone:520-313-1050
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4205171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ210142Medicaid