Basic Information
| Provider Information | |||||||||
| NPI: | 1104002427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5107 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106148612 | ||||||||
| FaxNumber: | 2106155596 | ||||||||
| Practice Location | |||||||||
| Address1: | 5107 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106148612 | ||||||||
| FaxNumber: | 2106155596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.