Basic Information
| Provider Information | |||||||||
| NPI: | 1811215239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REGIS | ||||||||
| FirstName: | REGINALD | ||||||||
| MiddleName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 646 RUTLAND RD | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112031849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3477582904 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9715 64TH RD | ||||||||
| Address2: | |||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113742250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184595592 | ||||||||
| FaxNumber: | 7184596047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2010 | ||||||||
| LastUpdateDate: | 05/10/2010 | ||||||||
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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 | 164W00000X | 295491 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.