Healthcare Provider Details

I. General information

NPI: 1174984678
Provider Name (Legal Business Name): MICHAEL REID CRNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WASHINGTON ST STE 155
COLTON CA
92324-4196
US

IV. Provider business mailing address

PO BOX 1712
LOMA LINDA CA
92354-0150
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-5752
  • Fax:
Mailing address:
  • Phone: 909-731-5794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL T REID
Title or Position: OWNER
Credential:
Phone: 909-731-5794