Healthcare Provider Details

I. General information

NPI: 1023093929
Provider Name (Legal Business Name): RICHARD WILLIAM REIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NORTH PEPPER AVENUE 2ND FLOOR, ANESTHESIA DEPT. INLAND EMPIRE ANESTHESIA MEDICAL GROUP, INC.
COLTON CA
92324-0765
US

IV. Provider business mailing address

PO BOX 765
COLTON CA
92324-0800
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-2440
  • Fax: 909-580-2441
Mailing address:
  • Phone: 909-889-7084
  • Fax: 909-889-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA716
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberNA716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: