Provider Demographics
NPI:1962778464
Name:REAGER, ERNEST
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:REAGER
Suffix:
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 1:8862 PINEY BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-3318
Mailing Address - Country:US
Mailing Address - Phone:804-683-2580
Mailing Address - Fax:
Practice Address - Street 1:5408 DISCOVERY PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2893
Practice Address - Country:US
Practice Address - Phone:757-220-8552
Practice Address - Fax:757-220-0162
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001491111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0104001491OtherLICENSE NUMBER