=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245630003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO REYES MS, SCAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2014
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 476 HUBBARD DR
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29720-5615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-313-7190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 261 SUMMERS TRACE DR
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-8394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-693-0973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1952
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------