=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225756067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REYNOLDS CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 08/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1231 MAPLE AVE SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24016-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-342-9445
-----------------------------------------------------
Fax | 540-342-9446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1231 MAPLE AVE SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24016-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-342-9445
-----------------------------------------------------
Fax | 540-342-9446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DALE EUGENE REYNOLDS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 540-342-9445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------