Provider Demographics
NPI:1104186667
Name:REJUV INTEGRATIVE MEDICAL PRACTICE SHAWN C SNIDER
Entity Type:Organization
Organization Name:REJUV INTEGRATIVE MEDICAL PRACTICE SHAWN C SNIDER
Other - Org Name:LIFERX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:SNIDER
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:309-622-3002
Mailing Address - Street 1:405 N HERSHEY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3527
Mailing Address - Country:US
Mailing Address - Phone:309-622-3002
Mailing Address - Fax:309-263-4611
Practice Address - Street 1:405 N HERSHEY RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3527
Practice Address - Country:US
Practice Address - Phone:309-622-3002
Practice Address - Fax:309-263-4611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.110856261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service