Provider Demographics
NPI:1871799916
Name:MICKIE REYNOLDS
Entity type:Organization
Organization Name:MICKIE REYNOLDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICKIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:505-257-4577
Mailing Address - Street 1:506 WINGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-9327
Mailing Address - Country:US
Mailing Address - Phone:505-257-4577
Mailing Address - Fax:
Practice Address - Street 1:506 WINGFIELD ST
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-9327
Practice Address - Country:US
Practice Address - Phone:505-257-4577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3271251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM03112620000OtherCRS ID
NM05700752Medicaid
NM03112620000OtherCRS ID