Provider Demographics
NPI:1215163696
Name:DR REY DE LOS ANGELES, MD, LLC
Entity type:Organization
Organization Name:DR REY DE LOS ANGELES, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE LOS ANGELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-384-4739
Mailing Address - Street 1:1811 W 2ND ST
Mailing Address - Street 2:SUITE 245
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5413
Mailing Address - Country:US
Mailing Address - Phone:308-384-4739
Mailing Address - Fax:308-384-9195
Practice Address - Street 1:1811 W 2ND ST
Practice Address - Street 2:SUITE 245
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-5413
Practice Address - Country:US
Practice Address - Phone:308-384-4739
Practice Address - Fax:308-384-9195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE186362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098585Medicare PIN