Provider Demographics
NPI:1700132701
Name:REYES, GEORGIA LUCILLE (BACHELORS)
Entity type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:LUCILLE
Last Name:REYES
Suffix:
Gender:F
Credentials:BACHELORS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 LADYSLIPPER LN
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-8827
Mailing Address - Country:US
Mailing Address - Phone:989-860-8148
Mailing Address - Fax:
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-797-3477
Practice Address - Fax:989-797-3477
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker