Provider Demographics
NPI:1629213814
Name:REJUVANATION
Entity Type:Organization
Organization Name:REJUVANATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNP
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SNIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:309-278-0566
Mailing Address - Street 1:11 CURRENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-9398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 CURRENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-9398
Practice Address - Country:US
Practice Address - Phone:309-678-4243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005824363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty