=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326464124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALDO REYES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2014
-----------------------------------------------------
Last Update Date | 03/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 N FLOWER ST
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92703-2361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-647-6092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5731 PLACERVILLE PL
-----------------------------------------------------
City | YORBA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92886-6040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2400X
-----------------------------------------------------
Taxonomy Name | Prison Health Clinic/Center
-----------------------------------------------------
License Number | 579162
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------