Provider Demographics
NPI:1740898139
Name:REYES, MATTHEW RUSSELL (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RUSSELL
Last Name:REYES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3191 MISSION INN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4188
Mailing Address - Country:US
Mailing Address - Phone:951-684-2874
Mailing Address - Fax:951-684-2980
Practice Address - Street 1:3191 MISSION INN AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4188
Practice Address - Country:US
Practice Address - Phone:951-376-2692
Practice Address - Fax:961-684-2980
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298987225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist