Healthcare Provider Details

I. General information

NPI: 1922393123
Provider Name (Legal Business Name): MR. KEVIN MICHAEL REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 RENSSELAER STREET
RENSSELAER FALLS NY
13680-0011
US

IV. Provider business mailing address

210 RENSSELAER STREET
RENSSELAER FALLS NY
13680-0011
US

V. Phone/Fax

Practice location:
  • Phone: 315-261-9536
  • Fax:
Mailing address:
  • Phone: 315-261-9536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: