=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043659378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REYNA HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2013
-----------------------------------------------------
Last Update Date | 06/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 945 EDWIN DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-3066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-962-4770
-----------------------------------------------------
Fax | 757-961-5869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5321 HICKORY RDG
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-6681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-650-5312
-----------------------------------------------------
Fax | 757-961-5869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR / COO
-----------------------------------------------------
Name | MR. REYNALDO MENDOZA DELA CRUZ
-----------------------------------------------------
Credential | MECHANICAL ENGINEER
-----------------------------------------------------
Telephone | 757-650-5312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 1958
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------