1396868824 NPI number — HEALTH REJUVENATIONS CONSULTANT, INC.

Table of content: (NPI 1396868824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396868824 NPI number — HEALTH REJUVENATIONS CONSULTANT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH REJUVENATIONS CONSULTANT, INC.
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:
1396868824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4588 BOULDERCREST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENWOOD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30294-3613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-731-6107
Provider Business Mailing Address Fax Number:
404-366-9947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
194 JONESBORO RD
Provider Second Line Business Practice Location Address:
SUITE A-6
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30236-4812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-731-6107
Provider Business Practice Location Address Fax Number:
404-366-9947
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATILLO
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
D'NIN
Authorized Official Title or Position:
CEO-PSYCHOLOGIST
Authorized Official Telephone Number:
404-731-6107

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1594 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 004196 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01068080 . This is a "AMERIGROUP CORPORATION" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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