Provider Demographics
NPI:1770168536
Name:REYNOSO, JEREMY HECTOR (PTA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:HECTOR
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 MESA DR APT 19
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-0111
Mailing Address - Country:US
Mailing Address - Phone:949-259-3921
Mailing Address - Fax:
Practice Address - Street 1:255 E RINCON ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1367
Practice Address - Country:US
Practice Address - Phone:951-523-8509
Practice Address - Fax:951-221-8475
Is Sole Proprietor?:No
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51014208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation