Provider Demographics
NPI:1396983581
Name:REYNOLDS, DAN DAWAYNE (R EEG T , CNIM)
Entity type:Individual
Prefix:MR
First Name:DAN
Middle Name:DAWAYNE
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:R EEG T , CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 GODDARD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4610
Mailing Address - Country:US
Mailing Address - Phone:217-494-4243
Mailing Address - Fax:949-336-5113
Practice Address - Street 1:10207 CHARLES ST
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-8922
Practice Address - Country:US
Practice Address - Phone:217-494-4243
Practice Address - Fax:574-968-6448
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1000246ZE0600X
IL39012472E0500X
CA2472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic