Provider Demographics
NPI:1306595244
Name:PREDESTIN, REGINAL (OWNER)
Entity type:Individual
Prefix:
First Name:REGINAL
Middle Name:
Last Name:PREDESTIN
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N BISHOP AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2455
Mailing Address - Country:US
Mailing Address - Phone:203-572-6065
Mailing Address - Fax:
Practice Address - Street 1:250 N BISHOP AVE APT 2
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2455
Practice Address - Country:US
Practice Address - Phone:203-572-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A