1255655239 NPI number — REJUVENATE HEALTH CHIROPRACTIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255655239 NPI number — REJUVENATE HEALTH CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REJUVENATE HEALTH CHIROPRACTIC
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:
1255655239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 E BELT LINE RD
Provider Second Line Business Mailing Address:
APT 924
Provider Business Mailing Address City Name:
COPPELL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75019-4231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-802-6497
Provider Business Mailing Address Fax Number:
972-947-3992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 BAYOU PINES EAST DR
Provider Second Line Business Practice Location Address:
SUITE R
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-7196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-802-6497
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
ATHENA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
337-802-6497

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1556 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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