1396868824 NPI number — HEALTH REJUVENATIONS CONSULTANT, INC.

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 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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