Provider Demographics
NPI:1396983300
Name:REYNOLDS, SETH MICHAEL (BOC-O, CP)
Entity type:Individual
Prefix:MR
First Name:SETH
Middle Name:MICHAEL
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:BOC-O, CP
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 428
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-0428
Mailing Address - Country:US
Mailing Address - Phone:828-684-1644
Mailing Address - Fax:828-684-1104
Practice Address - Street 1:3845 HENDERSONVILLE RD
Practice Address - Street 2:
Practice Address - City:FLETCHER
Practice Address - State:NC
Practice Address - Zip Code:28732-8241
Practice Address - Country:US
Practice Address - Phone:828-684-1644
Practice Address - Fax:828-684-1104
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC49811222Z00000X
NC224P00000X
DECP003528224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCP003528OtherCERTIFIED PROSTHETIST
NC7795423Medicaid
C49811OtherCERTIFIED ORTHOTIST