1194711978 NPI number — REJUVENATION CENTER LLC

Table of content: (NPI 1194711978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194711978 NPI number — REJUVENATION CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REJUVENATION CENTER LLC
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:
NEWSOM COSMETIC LLC
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:
1194711978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13904 N DALE MABRY HWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33618-2446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-908-2020
Provider Business Mailing Address Fax Number:
813-908-2133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4211 US HIGHWAY 27 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBRING
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-382-7588
Provider Business Practice Location Address Fax Number:
863-385-1233
Provider Enumeration Date:
09/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NEWSOM
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
H
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
813-908-2020

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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