=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063432029
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS WESLEY REIS C.P.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5460 MERLE HAY RD STE C
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50131-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-254-0244
-----------------------------------------------------
Fax | 515-254-0309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5460 MERLE HAY RD STE C
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50131-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-254-0244
-----------------------------------------------------
Fax | 515-254-0309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | CP-1182
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------