Provider Demographics
NPI:1265932891
Name:REYES, JEREMIAH (PCA)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 CAMBRIDGE ST APT 819
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-7488
Mailing Address - Country:US
Mailing Address - Phone:702-960-9269
Mailing Address - Fax:
Practice Address - Street 1:1785 E SAHARA AVE STE 485
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3757
Practice Address - Country:US
Practice Address - Phone:702-562-2348
Practice Address - Fax:702-598-0010
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005049778Medicaid