Provider Demographics
NPI:1063835411
Name:REJUVENESCENCE LLC
Entity Type:Organization
Organization Name:REJUVENESCENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCADOO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-397-3373
Mailing Address - Street 1:6785 WEAVER RD
Mailing Address - Street 2:STE D
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8055
Mailing Address - Country:US
Mailing Address - Phone:815-633-8586
Mailing Address - Fax:
Practice Address - Street 1:18205 BISCAYNE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2106
Practice Address - Country:US
Practice Address - Phone:305-901-0911
Practice Address - Fax:305-947-0752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11955208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty