Provider Demographics
NPI:1336561992
Name:REJUVENOS
Entity Type:Organization
Organization Name:REJUVENOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-481-3121
Mailing Address - Street 1:7843 E SABINO HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-7223
Mailing Address - Country:US
Mailing Address - Phone:520-481-3121
Mailing Address - Fax:
Practice Address - Street 1:2828 N STONE AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-4503
Practice Address - Country:US
Practice Address - Phone:520-481-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service