Provider Demographics
NPI:1710523220
Name:BODAM, REECE ARTHUR
Entity Type:Individual
Prefix:
First Name:REECE
Middle Name:ARTHUR
Last Name:BODAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2937
Mailing Address - Country:US
Mailing Address - Phone:208-369-4307
Mailing Address - Fax:208-369-4307
Practice Address - Street 1:211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2937
Practice Address - Country:US
Practice Address - Phone:208-369-4307
Practice Address - Fax:208-369-4503
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA3160237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDHA3160OtherSTATE LICENSE