Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 08002103A | IN |
NPI | 1003874645 |
---|---|
Provider Name | Dr. Jade Matthew Reynolds |
First Address | Berne, IN 46711-2375 |
Second Address | Berne, IN 46711-2375 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 30/10/2010 |