1023029535 NPI number — REBEL DISTRIBUTION CORP

Table of content: (NPI 1023029535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023029535 NPI number — REBEL DISTRIBUTION CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REBEL DISTRIBUTION CORP
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:
Provider Other Organization Name Type Code:
6
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:
1023029535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3607 OLD CONEJO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91320-2123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-375-0800
Provider Business Mailing Address Fax Number:
805-375-0885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3607 OLD CONEJO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91320-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-375-0800
Provider Business Practice Location Address Fax Number:
805-375-0885
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SETSER
Authorized Official First Name:
DESTRY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC VP
Authorized Official Telephone Number:
805-375-0800

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  WLS3004 , 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: 5623029 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com