Basic Information
| Provider Information | |||||||||
| NPI: | 1114559622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16940 HIGHWAY 14 STE C-J | ||||||||
| Address2: | |||||||||
| City: | MOJAVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935011238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618245020 | ||||||||
| FaxNumber: | 6618245026 | ||||||||
| Practice Location | |||||||||
| Address1: | 16940 HIGHWAY 14 STE C-J | ||||||||
| Address2: | |||||||||
| City: | MOJAVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935011238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618245020 | ||||||||
| FaxNumber: | 6618245026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.