Provider Demographics
NPI:1770714396
Name:KENNETH B. REHM, D.P.M.
Entity type:Organization
Organization Name:KENNETH B. REHM, D.P.M.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:REHM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-744-6226
Mailing Address - Street 1:1553 GRAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2427
Mailing Address - Country:US
Mailing Address - Phone:760-744-6226
Mailing Address - Fax:760-744-6277
Practice Address - Street 1:1600 S IMPERIAL AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4242
Practice Address - Country:US
Practice Address - Phone:760-335-3545
Practice Address - Fax:760-335-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2808332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E28081Medicaid
CA5287540002Medicare NSC
CA000E28081Medicaid