Provider Demographics
NPI:1518439603
Name:REYES, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA MARIE
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 THUMB MOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8329
Practice Address - Country:US
Practice Address - Phone:925-584-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA227900000X
227900000X
CA34664227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGroup - Single Specialty