Provider Demographics
NPI:1750623708
Name:REBNER, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:REBNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 BACON AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1175
Mailing Address - Country:US
Mailing Address - Phone:248-219-7199
Mailing Address - Fax:
Practice Address - Street 1:3622 BACON AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1175
Practice Address - Country:US
Practice Address - Phone:248-219-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-17
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist