Provider Demographics
NPI:1942552575
Name:ADVANCED REJUVENATION LLC
Entity Type:Organization
Organization Name:ADVANCED REJUVENATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIRSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-504-2204
Mailing Address - Street 1:2033 WOOD ST
Mailing Address - Street 2:210
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 2:210
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:2012-10-05
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty