Provider Demographics
NPI:1952711442
Name:REYNALDO, MASSIEL
Entity Type:Individual
Prefix:
First Name:MASSIEL
Middle Name:
Last Name:REYNALDO
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 1:4401 W BALLAST POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-5601
Mailing Address - Country:US
Mailing Address - Phone:813-775-8689
Mailing Address - Fax:
Practice Address - Street 1:4401 W BALLAST POINT BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-5601
Practice Address - Country:US
Practice Address - Phone:813-775-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12485310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility