Healthcare Provider Details

I. General information

NPI: 1104832039
Provider Name (Legal Business Name): MICHAEL T REID CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WASHINGTON ST STE. 100
COLTON CA
92324-7111
US

IV. Provider business mailing address

PO BOX 1448
RANCHO CUCAMONGA CA
91729-1448
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-2190
  • Fax:
Mailing address:
  • Phone: 909-946-5752
  • Fax: 909-985-3858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA 2132
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA2132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: