Healthcare Provider Details

I. General information

NPI: 1679991335
Provider Name (Legal Business Name): MARY REYNOLDS R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 541-440-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number32487DI-0
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: