Healthcare Provider Details

I. General information

NPI: 1891124954
Provider Name (Legal Business Name): LYLE J. REBER, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47110 WASHINGTON ST SUITE 103
LA QUINTA CA
92253-2186
US

IV. Provider business mailing address

47110 WASHINGTON ST SUITE 201
LA QUINTA CA
92253-2186
US

V. Phone/Fax

Practice location:
  • Phone: 760-625-1650
  • Fax: 760-625-1654
Mailing address:
  • Phone: 760-625-1653
  • Fax: 760-625-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG68674
License Number StateCA

VIII. Authorized Official

Name: DR. LYLE J. REBER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-625-1650