Basic Information
| Provider Information | |||||||||
| NPI: | 1295161735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3810 S COOPER ST | ||||||||
| Address2: | SUITE 144 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760154149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174664327 | ||||||||
| FaxNumber: | 8174681067 | ||||||||
| Practice Location | |||||||||
| Address1: | 3810 S COOPER ST | ||||||||
| Address2: | SUITE 144 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760154149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174664327 | ||||||||
| FaxNumber: | 8174681067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2013 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 80614 | TX | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.