Provider Demographics
NPI:1285002923
Name:REJUVECARE CLINIC
Entity Type:Organization
Organization Name:REJUVECARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH OTOUPALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-240-7396
Mailing Address - Street 1:7473 GROOMS RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-9798
Mailing Address - Country:US
Mailing Address - Phone:406-240-7396
Mailing Address - Fax:
Practice Address - Street 1:77 3RD AVENUE WEST N
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4049
Practice Address - Country:US
Practice Address - Phone:406-240-7396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty