Provider Demographics
NPI:1467147546
Name:REBEL ENTERPRISE LLC
Entity Type:Organization
Organization Name:REBEL ENTERPRISE LLC
Other - Org Name:THE FOOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:602-686-9594
Mailing Address - Street 1:3465 N ORCHARD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2855 E BROWN RD STE 18
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-4216
Practice Address - Country:US
Practice Address - Phone:602-345-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-06
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric