Provider Demographics
NPI:1235508243
Name:JOSE LUIS REYES
Entity type:Organization
Organization Name:JOSE LUIS REYES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WAIVER SUPPORT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:787-221-2198
Mailing Address - Street 1:77 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:CENTER HILL
Mailing Address - State:FL
Mailing Address - Zip Code:33514-4629
Mailing Address - Country:US
Mailing Address - Phone:787-221-2198
Mailing Address - Fax:
Practice Address - Street 1:77 E PARK ST
Practice Address - Street 2:
Practice Address - City:CENTER HILL
Practice Address - State:FL
Practice Address - Zip Code:33514-4629
Practice Address - Country:US
Practice Address - Phone:787-221-2198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-20
Last Update Date:2015-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization