Provider Demographics
NPI:1164256483
Name:LAKE, REGGIE LAMONT II
Entity type:Individual
Prefix:
First Name:REGGIE
Middle Name:LAMONT
Last Name:LAKE
Suffix:II
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 1:4000 GOVERNORS DR APT 4004B
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-3264
Mailing Address - Country:US
Mailing Address - Phone:251-644-9915
Mailing Address - Fax:
Practice Address - Street 1:9811 W CHARLESTON BLVD STE 2-641
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:281-742-9544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic