MEDICARE: CHAD ALLEN REIGEL KCSA

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	246ZS0410X	Surgical Technologist	SA 059	KY

General Provider Information

NPI Number	:	1710912258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD ALLEN REIGEL KCSA

Provider Business Mailing Address
First Line	:	313 AUTUMN BREEZE TRCE
Second Line	:
City	:	LAGRANGE
State	:	KY
Zip	:	40031-1392
Country	:	US
Telephone Number	:	502-225-6334
Fax Number	:	502-225-6334

Provider Business Practice Location Address
First Line	:	313 AUTUMN BREEZE TRCE
Second Line	:
City	:	LAGRANGE
State	:	KY
Zip	:	40031-1392
Country	:	US
Telephone Number	:	502-225-6334
Fax Number	:	502-225-6334

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	12/08/2020

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