Provider Demographics
NPI:1578284592
Name:REYES, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
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 1:19881 ADIRONDACK WAY
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-8053
Mailing Address - Country:US
Mailing Address - Phone:208-739-7650
Mailing Address - Fax:
Practice Address - Street 1:82 E STATE ST STE D
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6048
Practice Address - Country:US
Practice Address - Phone:208-739-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2679225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist