Provider Demographics
NPI:1619397247
Name:REJUVENATION WELLNESS LLC
Entity Type:Organization
Organization Name:REJUVENATION WELLNESS LLC
Other - Org Name:VITALOGY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:TAJ
Authorized Official - Last Name:SULTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-413-8599
Mailing Address - Street 1:2704 20TH STREET SOUTH
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209
Mailing Address - Country:US
Mailing Address - Phone:205-413-8599
Mailing Address - Fax:205-383-2425
Practice Address - Street 1:2704 20TH STREET SOUTH
Practice Address - Street 2:SUITE 104
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209
Practice Address - Country:US
Practice Address - Phone:205-413-8599
Practice Address - Fax:205-383-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL24915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH76494Medicare UPIN