1376005009 NPI number — REJUVENATION CARE CLINIC OF CENTRAL FLORIDA

Table of content: (NPI 1376005009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376005009 NPI number — REJUVENATION CARE CLINIC OF CENTRAL FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REJUVENATION CARE CLINIC OF CENTRAL FLORIDA
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:
1376005009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12221 E COLONIAL DR APT 1105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32826-4762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-641-9128
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2541 S VOLUSIA AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-9116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-641-9128
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
COPELAND
Authorized Official First Name:
CLAXTON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-641-9128

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L19000063350 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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