Provider Demographics
NPI:1427239862
Name:RANDAL DAVID REYNOLDS PHD LLC
Entity type:Organization
Organization Name:RANDAL DAVID REYNOLDS PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-440-3804
Mailing Address - Street 1:4401 WESTOWN PKWY STE 309
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6721
Mailing Address - Country:US
Mailing Address - Phone:515-440-3804
Mailing Address - Fax:
Practice Address - Street 1:4401 WESTOWN PKWY STE 309
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6721
Practice Address - Country:US
Practice Address - Phone:515-440-3804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I16414Medicare PIN