Provider Demographics
NPI:1265748818
Name:REJUVE MED SPA PLLC
Entity type:Organization
Organization Name:REJUVE MED SPA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-353-5570
Mailing Address - Street 1:630 EASTERN BYPASS
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2330
Mailing Address - Country:US
Mailing Address - Phone:859-353-5570
Mailing Address - Fax:859-353-5934
Practice Address - Street 1:630 EASTERN BYPASS
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2330
Practice Address - Country:US
Practice Address - Phone:859-353-5570
Practice Address - Fax:859-353-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3528P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty