Provider Demographics
NPI:1114623675
Name:REJUVAAH & REVVIVED
Entity Type:Organization
Organization Name:REJUVAAH & REVVIVED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWANDA
Authorized Official - Middle Name:SHAREE
Authorized Official - Last Name:FANTROY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:228-235-6015
Mailing Address - Street 1:820 S UNIVERSITY BLVD STE 2K
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-7860
Mailing Address - Country:US
Mailing Address - Phone:251-277-7373
Mailing Address - Fax:251-277-7376
Practice Address - Street 1:820 S UNIVERSITY BLVD STE 2K
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-7860
Practice Address - Country:US
Practice Address - Phone:251-277-7373
Practice Address - Fax:251-277-7376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy