Provider Demographics
NPI:1437316197
Name:REJUVENATION WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:REJUVENATION WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-785-4959
Mailing Address - Street 1:4730 E WARNER RD
Mailing Address - Street 2:STE 10
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3320
Mailing Address - Country:US
Mailing Address - Phone:480-785-4959
Mailing Address - Fax:
Practice Address - Street 1:4730 E WARNER RD STE 10
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-3320
Practice Address - Country:US
Practice Address - Phone:480-785-4959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
AZ5031305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ122867Medicare PIN