Provider Demographics
NPI:1629443643
Name:REJUVA MED
Entity Type:Organization
Organization Name:REJUVA MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRONICO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-907-0950
Mailing Address - Street 1:28945 STATE ROAD 54
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543
Mailing Address - Country:US
Mailing Address - Phone:813-907-0950
Mailing Address - Fax:813-907-7949
Practice Address - Street 1:28945 STATE ROAD 54
Practice Address - Street 2:SUITE 101
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543
Practice Address - Country:US
Practice Address - Phone:813-907-0950
Practice Address - Fax:813-907-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS004967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013795600Medicaid
FLB41510Medicare UPIN