Provider Demographics
NPI:1013495993
Name:REYNOLDS, JEFF G
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:G
Last Name:REYNOLDS
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 1:2540 CARDIGAN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5348
Mailing Address - Country:US
Mailing Address - Phone:719-660-6826
Mailing Address - Fax:719-218-1010
Practice Address - Street 1:11 WESTMARK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4738
Practice Address - Country:US
Practice Address - Phone:719-660-6826
Practice Address - Fax:719-218-1010
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23U713376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23U713OtherASSISTED LIVING