Provider Demographics
NPI:1871801670
Name:REYNOLDS, DAVID MICHAEL II (LPN)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:REYNOLDS
Suffix:II
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5363
Mailing Address - Country:US
Mailing Address - Phone:402-707-1879
Mailing Address - Fax:
Practice Address - Street 1:318 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5363
Practice Address - Country:US
Practice Address - Phone:402-707-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP50196164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE$$$$$$$$$02Medicaid