Healthcare Provider Details

I. General information

NPI: 1679110852
Provider Name (Legal Business Name): ERIC JAVIER REYES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W COTA ST
SHELTON WA
98584-2265
US

IV. Provider business mailing address

528 COURTSIDE ST SW APT C104
OLYMPIA WA
98502-8715
US

V. Phone/Fax

Practice location:
  • Phone: 503-348-3767
  • Fax:
Mailing address:
  • Phone: 360-581-8188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: