Provider Demographics
NPI:1932772977
Name:REYES, MILA ROSE DOMINGO
Entity Type:Individual
Prefix:
First Name:MILA ROSE
Middle Name:DOMINGO
Last Name:REYES
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 1:23421 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-5231
Mailing Address - Country:US
Mailing Address - Phone:310-999-5247
Mailing Address - Fax:
Practice Address - Street 1:2515 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90810-1519
Practice Address - Country:US
Practice Address - Phone:310-830-7803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA704541163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health