Healthcare Provider Details

I. General information

NPI: 1710613005
Provider Name (Legal Business Name): TYRONE REID
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4133 DEWEY AVE
ROCHESTER NY
14616-1214
US

IV. Provider business mailing address

4133 DEWEY AVE
ROCHESTER NY
14616-1214
US

V. Phone/Fax

Practice location:
  • Phone: 585-405-4858
  • Fax:
Mailing address:
  • Phone: 585-405-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number269486
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: