Healthcare Provider Details

I. General information

NPI: 1003087156
Provider Name (Legal Business Name): EDWARD REZA JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W ARDENE ST
BOISE ID
83709-2601
US

IV. Provider business mailing address

8631 W ARDENE ST
BOISE ID
83709-2601
US

V. Phone/Fax

Practice location:
  • Phone: 208-629-1904
  • Fax: 208-545-1846
Mailing address:
  • Phone: 208-629-1904
  • Fax: 208-545-1846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC28729
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8161070
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: