Healthcare Provider Details

I. General information

NPI: 1326108218
Provider Name (Legal Business Name): DAVID J REIS OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 64 OLD HIGH SCHOOL ROAD
SHIPROCK NM
87420
US

IV. Provider business mailing address

31277 CR L
MANCOS CO
81328
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-5163
  • Fax: 505-368-5502
Mailing address:
  • Phone: 505-649-2045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1762
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: