Provider Demographics
NPI:1013550987
Name:REJUVENTA MEDICAL CORP.
Entity Type:Organization
Organization Name:REJUVENTA MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUITO
Authorized Official - Middle Name:C
Authorized Official - Last Name:WINGFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-494-1002
Mailing Address - Street 1:1755 KRESKY AVE. BOX 16
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-669-0098
Mailing Address - Fax:360-669-0121
Practice Address - Street 1:1755 KRESKY AVE.
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:360-669-0098
Practice Address - Fax:360-669-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00048810OtherWASHINGTON STATE MEDICAL LICENSE
WA1699792242OtherNPI
WA1013550987Medicaid