Provider Demographics
NPI:1144738550
Name:REJUVENX OF WEST PALM BEACH, LLC
Entity Type:Organization
Organization Name:REJUVENX OF WEST PALM BEACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECANIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-422-1819
Mailing Address - Street 1:1470A ROYAL PALM BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1608
Mailing Address - Country:US
Mailing Address - Phone:561-422-1819
Mailing Address - Fax:
Practice Address - Street 1:1645 PALM BEACH LAKES BLVD STE 1200
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2214
Practice Address - Country:US
Practice Address - Phone:561-422-1819
Practice Address - Fax:561-422-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8849111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty