Basic Information
| Provider Information | |||||||||
| NPI: | 1407304025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | CARLOS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925064553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519018555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1881 BUSINESS CENTER DR | ||||||||
| Address2: | SUITE 10-A | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098902381 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2016 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.