MEDICARE: DR. JERRY RAY REAVIS DC

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	641	NC

General Provider Information

NPI Number	:	1649268905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY RAY REAVIS DC

Provider Business Mailing Address
First Line	:	3702 REYNOLDA RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-2232
Country	:	US
Telephone Number	:	336-925-1593
Fax Number	:	336-924-4333

Provider Business Practice Location Address
First Line	:	3702 REYNOLDA RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-2232
Country	:	US
Telephone Number	:	336-925-1593
Fax Number	:	336-924-4333

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	07/08/2007

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