Provider Demographics
NPI:1760636500
Name:REJUVENATING ADULT DAY CARE
Entity Type:Organization
Organization Name:REJUVENATING ADULT DAY CARE
Other - Org Name:REJUVENATING ADULT DAY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:L'KIENDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-214-0349
Mailing Address - Street 1:1023 N PINE ST
Mailing Address - Street 2:BLDG 4
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78202-1203
Mailing Address - Country:US
Mailing Address - Phone:210-214-0349
Mailing Address - Fax:210-595-7180
Practice Address - Street 1:1023 N PINE ST
Practice Address - Street 2:BLDG 4
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78202-1203
Practice Address - Country:US
Practice Address - Phone:210-214-0349
Practice Address - Fax:210-595-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid