Provider Demographics
NPI:1306181540
Name:DR TENORE'S FOUNTAIN OF YOUTH, CORP
Entity Type:Organization
Organization Name:DR TENORE'S FOUNTAIN OF YOUTH, CORP
Other - Org Name:FRESHSKIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TENORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-681-8821
Mailing Address - Street 1:806 CENTRAL AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-5613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 CENTRAL AVE STE 203
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-5613
Practice Address - Country:US
Practice Address - Phone:847-681-8821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR TENORE'S FOUNTAIN OF YOUTH, CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-28
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty