Provider Demographics
NPI:1760352439
Name:REYES, MICHAEL TAKODA
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TAKODA
Last Name:REYES
Suffix:
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 1:559 DAVIDSON GATEWAY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:559 DAVIDSON GATEWAY DR
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7033
Practice Address - Country:US
Practice Address - Phone:704-559-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-07
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP24500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist