MEDICARE: MR. CHARLES EDWARD REYNOLDS JR.

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	251E00000X	Home Health Agency	113004427	TN

General Provider Information

NPI Number	:	1346679990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES EDWARD REYNOLDS JR.

Provider Business Mailing Address
First Line	:	3514 CLEARBROOK ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38118-5547
Country	:	US
Telephone Number	:	901-362-6015
Fax Number	:	901-404-5106

Provider Business Practice Location Address
First Line	:	3514 CLEARBROOK ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38118-5547
Country	:	US
Telephone Number	:	901-362-6015
Fax Number	:	901-404-5106

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	11/07/2013

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