Healthcare Provider Details

I. General information

NPI: 1417537895
Provider Name (Legal Business Name): ISAAC CHRISTIAN REEB RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2021
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

IV. Provider business mailing address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

V. Phone/Fax

Practice location:
  • Phone: 920-222-9257
  • Fax:
Mailing address:
  • Phone: 920-222-9257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86132856
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1251435428
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: