Provider Demographics
NPI:1578797684
Name:REJUVENATE LIFE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:REJUVENATE LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENIL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-883-2095
Mailing Address - Street 1:1828 ASPEN LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2314
Mailing Address - Country:US
Mailing Address - Phone:920-883-2095
Mailing Address - Fax:
Practice Address - Street 1:44 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235
Practice Address - Country:US
Practice Address - Phone:920-818-0045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4464-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1497989677Medicaid