=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699066092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGINALD ATIENZA DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2011
-----------------------------------------------------
Last Update Date | 04/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21329 BUNKER DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48042-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-533-6658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21329 BUNKER DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48042-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-533-6658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501013132
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------