Healthcare Provider Details

I. General information

NPI: 1093178634
Provider Name (Legal Business Name): JOHN MCREYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BURLINGTON AVE
LA GRANGE IL
60525-2363
US

IV. Provider business mailing address

300 W BURLINGTON AVE
LA GRANGE IL
60525-2363
US

V. Phone/Fax

Practice location:
  • Phone: 708-579-2338
  • Fax:
Mailing address:
  • Phone: 708-579-2338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP000386342
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: