Healthcare Provider Details

I. General information

NPI: 1649955196
Provider Name (Legal Business Name): CHARLIE REYES TORREBLANCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 BUFORD DR
LAWRENCEVILLE GA
30043-2102
US

IV. Provider business mailing address

354 E CREEK BND
ATHENS GA
30605-4561
US

V. Phone/Fax

Practice location:
  • Phone: 470-712-5883
  • Fax:
Mailing address:
  • Phone: 678-522-8984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: