Provider Demographics
NPI:1043933179
Name:REYNOLDS, TRAVORIS D SR
Entity type:Individual
Prefix:
First Name:TRAVORIS
Middle Name:D
Last Name:REYNOLDS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-3830
Mailing Address - Country:US
Mailing Address - Phone:772-940-8356
Mailing Address - Fax:
Practice Address - Street 1:567 WHITNEY PLACE
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34950
Practice Address - Country:US
Practice Address - Phone:772-940-8356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator