Provider Demographics
NPI:1891270625
Name:WHITLEY, REGINALD L JR
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:L
Last Name:WHITLEY
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 1:1708 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7207
Mailing Address - Country:US
Mailing Address - Phone:662-537-6652
Mailing Address - Fax:
Practice Address - Street 1:1708 BILLINGS ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7207
Practice Address - Country:US
Practice Address - Phone:662-537-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver