1245541069 NPI number — REJUVENATING LIVES LLC

Table of content: (NPI 1245541069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245541069 NPI number — REJUVENATING LIVES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REJUVENATING LIVES 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:
Provider Other Organization Name Type Code:
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:
1245541069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4913 PROFESSIONAL CT STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27609-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-916-8100
Provider Business Mailing Address Fax Number:
984-377-4381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4913 PROFESSIONAL CT STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-1926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-907-3512
Provider Business Practice Location Address Fax Number:
984-377-4381
Provider Enumeration Date:
06/25/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
EBONIE
Authorized Official Middle Name:
KURTINA-JIMEKE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-916-8100

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: HC4151 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 305S00000X , with the licence number: HC4151 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X , with the licence number: HC4151 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2055X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6602070 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".