Provider Demographics
NPI:1942736327
Name:REYNA, RICHARD PANTOJA (LVN)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:PANTOJA
Last Name:REYNA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23119 COTTONWOOD AVE BLD A SUITE 110
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-413-5678
Mailing Address - Fax:951-413-5660
Practice Address - Street 1:23119 COTTONWOOD AVE BLD A SUITE 110
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553
Practice Address - Country:US
Practice Address - Phone:951-413-5678
Practice Address - Fax:951-413-5660
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN230721164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse