Provider Demographics
NPI:1316090616
Name:REYNOLDS, EDWARD JOHN (DC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JOHN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25431 CABOT RD
Mailing Address - Street 2:#110
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5518
Mailing Address - Country:US
Mailing Address - Phone:949-716-1900
Mailing Address - Fax:949-716-1919
Practice Address - Street 1:25431 CABOT RD
Practice Address - Street 2:#110
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5518
Practice Address - Country:US
Practice Address - Phone:949-716-1900
Practice Address - Fax:949-716-1919
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20364111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20364OtherMEDICAL LICENCE