Provider Demographics
NPI:1467520437
Name:MD CENTER FOR FACIAL REJUVENATION
Entity Type:Organization
Organization Name:MD CENTER FOR FACIAL REJUVENATION
Other - Org Name:RENEWMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:RODNEY
Authorized Official - Last Name:JOHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-424-3223
Mailing Address - Street 1:6440 WASATCH BLVD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3511
Mailing Address - Country:US
Mailing Address - Phone:801-424-3223
Mailing Address - Fax:801-424-3228
Practice Address - Street 1:6440 WASATCH BLVD
Practice Address - Street 2:SUITE 390
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3511
Practice Address - Country:US
Practice Address - Phone:801-424-3223
Practice Address - Fax:801-424-3228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6139294-1205261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery