1013550987 NPI number — REJUVENTA MEDICAL CORP.

Table of content: (NPI 1013550987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013550987 NPI number — REJUVENTA MEDICAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REJUVENTA MEDICAL CORP.
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:
1013550987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1755 KRESKY AVE. BOX 16
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-669-0098
Provider Business Mailing Address Fax Number:
360-669-0121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 KRESKY AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-669-0098
Provider Business Practice Location Address Fax Number:
360-669-0121
Provider Enumeration Date:
10/23/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WINGFIELD
Authorized Official First Name:
GUITO
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
917-494-1002

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD00048810 . This is a "WASHINGTON STATE MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1699792242 . This is a "NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1013550987 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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