Healthcare Provider Details

I. General information

NPI: 1629261375
Provider Name (Legal Business Name): REYNA R CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 S STATE COLLEGE BLVD SUITE 3-K
ANAHEIM CA
92806-5724
US

IV. Provider business mailing address

1440 S STATE COLLEGE BLVD SUITE 3-K
ANAHEIM CA
92806-5724
US

V. Phone/Fax

Practice location:
  • Phone: 714-758-0660
  • Fax: 714-758-0770
Mailing address:
  • Phone: 714-758-0660
  • Fax: 714-758-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0207X
TaxonomyMobile Mammography Clinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberFAC33625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: