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NPI Code Detail

MEDICARE: KELLY MARIE REAVIS M.S.

MEDICARE: KELLY MARIE REAVIS M.S.
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
1231H00000XAudiologistAU2627CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12627OTHERCAAUDIOLOGIST LICENSE

General Provider Information

NPI Number : 1467618991
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY MARIE REAVIS M.S.
Provider Business Mailing Address
First Line : 488 E OCEAN BLVD
Second Line : #207
City : LONG BEACH
State : CA
Zip : 90802-4761
Country : US
Telephone Number : 503-970-6691
Fax Number : 562-439-2232
Provider Business Practice Location Address
First Line : 5842 E NAPLES PLZ
Second Line :
City : LONG BEACH
State : CA
Zip : 90803-5039
Country : US
Telephone Number : 562-439-9539
Fax Number : 562-439-2232
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/04/2008
Last Update Date : 08/04/2008

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