1770714396 NPI number — KENNETH B. REHM, D.P.M.

Table of content: (NPI 1770714396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770714396 NPI number — KENNETH B. REHM, D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH B. REHM, D.P.M.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DIABETIC FOOT & WOUND MGM
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770714396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1553 GRAND AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SAN MARCOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92078-2427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-744-6226
Provider Business Mailing Address Fax Number:
760-744-6277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 S IMPERIAL AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-335-3545
Provider Business Practice Location Address Fax Number:
760-335-3613
Provider Enumeration Date:
07/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REHM
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-744-6226

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  E2808 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000E28081 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".