Healthcare Provider Details

I. General information

NPI: 1366657488
Provider Name (Legal Business Name): REBEL DISTRIBUTORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 OLD CONEJO RD
THOUSAND OAKS CA
91320-2123
US

IV. Provider business mailing address

3607 OLD CONEJO RD
THOUSAND OAKS CA
91320-2123
US

V. Phone/Fax

Practice location:
  • Phone: 805-214-0900
  • Fax: 805-214-0950
Mailing address:
  • Phone: 805-214-0900
  • Fax: 805-214-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberWLS3004
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberWLS3004
License Number StateCA

VIII. Authorized Official

Name: MR. DESTRY SETSER
Title or Position: CEO/OWNER
Credential:
Phone: 877-732-3579