Provider Demographics
NPI:1245791235
Name:A REJUVENATED HEALTHCARE LLC
Entity Type:Organization
Organization Name:A REJUVENATED HEALTHCARE LLC
Other - Org Name:A REJUVENATED HEALTHCARE LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-767-0168
Mailing Address - Street 1:3641 TYRONE BLVD N STE 3
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1150
Mailing Address - Country:US
Mailing Address - Phone:727-301-9628
Mailing Address - Fax:
Practice Address - Street 1:3641 TYRONE BLVD N STE 3
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1150
Practice Address - Country:US
Practice Address - Phone:727-301-9628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-31
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty