Provider Demographics
NPI:1750264784
Name:REYNOLDS, LACI
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LAVERNE CT SE
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30173-2417
Mailing Address - Country:US
Mailing Address - Phone:706-767-6188
Mailing Address - Fax:
Practice Address - Street 1:10 LAVERNE CT SE
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:GA
Practice Address - Zip Code:30173-2417
Practice Address - Country:US
Practice Address - Phone:706-767-6188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1146350247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other