Provider Demographics
NPI:1922094119
Name:REYNOLDS, JOHN THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 TERRA WEST DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4536
Mailing Address - Country:US
Mailing Address - Phone:815-235-7858
Mailing Address - Fax:815-235-7913
Practice Address - Street 1:630 TERRA WEST DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4536
Practice Address - Country:US
Practice Address - Phone:815-235-7858
Practice Address - Fax:815-235-7913
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5979340OtherCIGNA
IL004932381OtherBC/BS
IL2017038OtherFIRST HEALTH
IL7531336OtherAETNA - PPO
IL3474535OtherAETNA - HMO
IL2017038OtherFIRST HEALTH
IL203278Medicare ID - Type Unspecified