Provider Demographics
NPI:1891592176
Name:REYES, CLARENCE DAISUKE
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:DAISUKE
Last Name:REYES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E 2100 S UNIT 109
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2860
Mailing Address - Country:US
Mailing Address - Phone:808-349-9655
Mailing Address - Fax:
Practice Address - Street 1:555 E 2100 S UNIT 109
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2860
Practice Address - Country:US
Practice Address - Phone:808-349-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program