Provider Demographics
NPI:1245630003
Name:REYES, MARIO (MS, SCAT, ATC)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:MS, SCAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 SUMMERS TRACE DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8394
Mailing Address - Country:US
Mailing Address - Phone:850-693-0973
Mailing Address - Fax:
Practice Address - Street 1:476 HUBBARD DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-5615
Practice Address - Country:US
Practice Address - Phone:803-313-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer