Healthcare Provider Details

I. General information

NPI: 1205758570
Provider Name (Legal Business Name): RAFAEL REYES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6736 LAUREL CANYON BLVD STE 200
NORTH HOLLYWOOD CA
91606-1576
US

IV. Provider business mailing address

6312 REDBIRD DR
PICO RIVERA CA
90660-3479
US

V. Phone/Fax

Practice location:
  • Phone: 818-755-8786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: