Provider Demographics
NPI:1376726158
Name:TOM REIS PROSTHETICS LLC
Entity Type:Organization
Organization Name:TOM REIS PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:REIS
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:515-254-0244
Mailing Address - Street 1:5460 MERLE HAY RD STE C
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1239
Mailing Address - Country:US
Mailing Address - Phone:515-254-0244
Mailing Address - Fax:515-254-0309
Practice Address - Street 1:5460 MERLE HAY RD STE C
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1239
Practice Address - Country:US
Practice Address - Phone:515-254-0244
Practice Address - Fax:515-254-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IACP-1182335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20927OtherWELLMARK
IA0198226Medicaid
IA0198226Medicaid