Provider Demographics
NPI:1396810776
Name:REYNOSO, ROBERT L (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10727 PARAMOUNT BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3336
Mailing Address - Country:US
Mailing Address - Phone:562-862-0754
Mailing Address - Fax:562-862-2016
Practice Address - Street 1:10727 PARAMOUNT BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3336
Practice Address - Country:US
Practice Address - Phone:562-862-0754
Practice Address - Fax:562-862-2016
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC14210Medicare UPIN