Provider Demographics
NPI:1932722410
Name:REISER, ADDISON JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:JAMES
Last Name:REISER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 ROUTE 66 E
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2648
Mailing Address - Country:US
Mailing Address - Phone:573-774-3833
Mailing Address - Fax:
Practice Address - Street 1:310 ROUTE 66 E
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2648
Practice Address - Country:US
Practice Address - Phone:573-774-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018035179225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist