=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427400506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODERICK REYES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2016
-----------------------------------------------------
Last Update Date | 07/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 W CAMPBELL AVE SUIT 102
-----------------------------------------------------
City | CAMPBELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95008-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-871-4965
-----------------------------------------------------
Fax | 408-871-4904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 884 BING DR APT. 4
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95051-4944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-887-5031
-----------------------------------------------------
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 |
-----------------------------------------------------