Provider Demographics
NPI:1811566193
Name:LOOK BACK REJUVENATION, LLC.
Entity Type:Organization
Organization Name:LOOK BACK REJUVENATION, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:AGACNP-BC
Authorized Official - Phone:603-440-5803
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:MERRIMACK
Mailing Address - State:NH
Mailing Address - Zip Code:03054-0082
Mailing Address - Country:US
Mailing Address - Phone:603-440-5803
Mailing Address - Fax:
Practice Address - Street 1:382 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5046
Practice Address - Country:US
Practice Address - Phone:603-440-5803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty