Healthcare Provider Details

I. General information

NPI: 1396459343
Provider Name (Legal Business Name): JOSEPH DANIEL REYES 15792-RAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 11/16/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11894 ROSECRANS AVE
NORWALK CA
90650
US

IV. Provider business mailing address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

V. Phone/Fax

Practice location:
  • Phone: 562-929-7188
  • Fax: 562-929-7575
Mailing address:
  • Phone: 949-239-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15792-RAC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: