Provider Demographics
NPI:1457565533
Name:REYNOLDS, CHARLES LEE (MED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 ROSEDOWN ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-3636
Mailing Address - Country:US
Mailing Address - Phone:903-297-7150
Mailing Address - Fax:903-247-3424
Practice Address - Street 1:434 E LOOP 281
Practice Address - Street 2:STE. 103
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7932
Practice Address - Country:US
Practice Address - Phone:903-247-3422
Practice Address - Fax:903-247-3424
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATO5392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer