=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497912802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN REYES TAGLE DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2008
-----------------------------------------------------
Last Update Date | 12/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 153 E SPRING ST
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45885-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-459-1477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1324 S KNOXVILLE AVE
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45885-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-459-1477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10836
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4034
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------