Provider Demographics
NPI:1912781139
Name:SOLOMON, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4782 OSPREY WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-9104
Mailing Address - Country:US
Mailing Address - Phone:863-242-3691
Mailing Address - Fax:
Practice Address - Street 1:963 S LAKE SHORE WAY
Practice Address - Street 2:
Practice Address - City:LAKE ALFRED
Practice Address - State:FL
Practice Address - Zip Code:33850-3321
Practice Address - Country:US
Practice Address - Phone:863-242-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment