Provider Demographics
NPI:1265188718
Name:REYNOLDS, MICHAEL CASEY I
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CASEY
Last Name:REYNOLDS
Suffix:I
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 1:1500 BEVILLE RD STE 605
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5644
Mailing Address - Country:US
Mailing Address - Phone:386-788-0646
Mailing Address - Fax:
Practice Address - Street 1:1500 BEVILLE RD STE 605
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5644
Practice Address - Country:US
Practice Address - Phone:386-788-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5394237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist