MEDICARE: KEITH REYNOLDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	12767	TX

General Provider Information

NPI Number	:	1316422124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH REYNOLDS

Provider Business Mailing Address
First Line	:	2100 ROOSEVELT DR STE D
Second Line	:
City	:	DALWORTHINGTON GARDENS
State	:	TX
Zip	:	76013-5939
Country	:	US
Telephone Number	:	817-422-6069
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 ROOSEVELT DR STE D
Second Line	:
City	:	DALWORTHINGTON GARDENS
State	:	TX
Zip	:	76013-5939
Country	:	US
Telephone Number	:	817-422-6069
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2018
Last Update Date	:	09/27/2018

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Directions to “ KEITH REYNOLDS ” Practice Location

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