Provider Demographics
NPI:1740583749
Name:REJUVENATE MED SPA
Entity Type:Organization
Organization Name:REJUVENATE MED SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MD
Authorized Official - Prefix:
Authorized Official - First Name:ALTAGRACIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-925-8100
Mailing Address - Street 1:1111 BRICKELL AVE FL 11
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33131-3122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 BRICKELL AVE FL 11
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-3122
Practice Address - Country:US
Practice Address - Phone:954-925-8100
Practice Address - Fax:954-827-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87277261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267920500Medicaid