Healthcare Provider Details

I. General information

NPI: 1841120938
Provider Name (Legal Business Name): ELLIS REIBSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLIS ROBERTS

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 CRESTWOOD LN
IDAHO FALLS ID
83404-4979
US

IV. Provider business mailing address

686 SUMMIT AVE
PHILADELPHIA PA
19128-2318
US

V. Phone/Fax

Practice location:
  • Phone: 208-996-2692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: