Healthcare Provider Details

I. General information

NPI: 1912351792
Provider Name (Legal Business Name): REAGAN GIELINCKI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N PATTERSON RD
WAYLAND MI
49348-9095
US

IV. Provider business mailing address

410 N PATTERSON RD
WAYLAND MI
49348-9095
US

V. Phone/Fax

Practice location:
  • Phone: 801-388-1640
  • Fax:
Mailing address:
  • Phone: 801-388-1640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: REAGAN FRANCES GIELINCKI
Title or Position: OWNER
Credential: MS, OTR, IBCLC
Phone: 801-388-1640