=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053740670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYLE J REBER MD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2013
-----------------------------------------------------
Last Update Date | 11/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47110 WASHINGTON ST STE 103
-----------------------------------------------------
City | LA QUINTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92253-2186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-972-4580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6449
-----------------------------------------------------
City | LA QUINTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92248-6449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-972-4580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LYLE JONATHAN REBER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 760-972-4580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------