Provider Demographics
NPI:1477936045
Name:REYES, KRYSTAL (PT)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:672 E WYTHE CREEK CT
Practice Address - Street 2:SUITE 103
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5216
Practice Address - Country:US
Practice Address - Phone:208-922-9828
Practice Address - Fax:208-922-3499
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist