Basic Information
| Provider Information | |||||||||
| NPI: | 1548305238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNAGA | ||||||||
| FirstName: | SERGIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1632 W 204TH ST | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905011605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107871500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 370 CRENSHAW BLVD | ||||||||
| Address2: | SUITE E-100 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905031727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1307871500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.