Provider Demographics
NPI:1427672518
Name:MIMS, REGINALD BERNARD SR
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:BERNARD
Last Name:MIMS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-6237
Mailing Address - Country:US
Mailing Address - Phone:407-625-1995
Mailing Address - Fax:
Practice Address - Street 1:105 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-6237
Practice Address - Country:US
Practice Address - Phone:407-625-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health