Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4484 | MN |
NPI | 1003902206 |
---|---|
Provider Name | Dr. Mitch L Reynolds |
First Address | Pipestone, MN 56164-1669 |
Second Address | Pipestone, MN 56164-1669 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04016009 | (05) | MN |
228L3PI | BLUECROSS BLUESHIELD (01) | MN |