Provider Demographics
NPI:1306449269
Name:REYES CACERES, EDWARD GONZALO (MA94672)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:GONZALO
Last Name:REYES CACERES
Suffix:
Gender:M
Credentials:MA94672
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 ARLEIGH CT APT 107
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-7856
Mailing Address - Country:US
Mailing Address - Phone:754-249-3626
Mailing Address - Fax:
Practice Address - Street 1:6551 ARLEIGH CT APT 107
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-7856
Practice Address - Country:US
Practice Address - Phone:754-249-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA94672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist