Provider Demographics
NPI:1053431825
Name:REYES, CORAZON J (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:CORAZON
Middle Name:J
Last Name:REYES
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3973 LOCKPORT DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2116
Mailing Address - Country:US
Mailing Address - Phone:314-739-6332
Mailing Address - Fax:
Practice Address - Street 1:6065 HELEN AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:MO
Practice Address - Zip Code:63134-2013
Practice Address - Country:US
Practice Address - Phone:314-522-6410
Practice Address - Fax:314-522-0821
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025465133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered