Basic Information
| Provider Information | |||||||||
| NPI: | 1780628420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25229 S SUNLAKES BLVD | ||||||||
| Address2: | STE 119 | ||||||||
| City: | SUNLAKES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808836734 | ||||||||
| FaxNumber: | 4808958143 | ||||||||
| Practice Location | |||||||||
| Address1: | 1076 W CHANDLER BLVD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808211997 | ||||||||
| FaxNumber: | 4808211887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/07/2011 | ||||||||
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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 | 174400000X | 6276 | AZ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 6276 | 01 | AZ | STATE LICENSE | OTHER | 3781 | 01 | OK | PHYSICAL THERAPIST | OTHER |