Healthcare Provider Details

I. General information

NPI: 1902139066
Provider Name (Legal Business Name): LAURA THALIA REIS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA ARNHEIM DANIS D.O.

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-3000
  • Fax: 208-463-3046
Mailing address:
  • Phone: 208-985-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4513
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number4513
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0889
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: