Provider Demographics
NPI:1710238597
Name:ADVANCED REJUVINATION
Entity Type:Organization
Organization Name:ADVANCED REJUVINATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEURANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-330-8553
Mailing Address - Street 1:2033 WOOD ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-7900
Mailing Address - Country:US
Mailing Address - Phone:941-330-8553
Mailing Address - Fax:941-330-9853
Practice Address - Street 1:2033 WOOD ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-7900
Practice Address - Country:US
Practice Address - Phone:941-330-8553
Practice Address - Fax:941-330-9853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7524111NN0400X
FLAP2975171100000X
FLME305552083S0010X
FLOS5165208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty