=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245742915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUSTAVO REYES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2017
-----------------------------------------------------
Last Update Date | 11/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1522 E 102ND ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90002-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-385-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10221 S. COMPTON AVENUE SUITES 104, 202, 203
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90002-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-783-4677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------