Provider Demographics
NPI:1265528814
Name:REYES, KENNEDY (BSPT)
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10163-1057
Mailing Address - Country:US
Mailing Address - Phone:718-805-6537
Mailing Address - Fax:
Practice Address - Street 1:170-13 HILLSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-657-2706
Practice Address - Fax:718-657-2420
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023615-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist