Provider Demographics
NPI:1780158287
Name:REJUVENATION MEDSPA
Entity type:Organization
Organization Name:REJUVENATION MEDSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PEASAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-841-1293
Mailing Address - Street 1:1400 JOHNSON AVE STE 4A
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1063
Mailing Address - Country:US
Mailing Address - Phone:304-848-9998
Mailing Address - Fax:304-848-9996
Practice Address - Street 1:1400 JOHNSON AVE STE 4A
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1063
Practice Address - Country:US
Practice Address - Phone:304-848-9998
Practice Address - Fax:304-848-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1942OtherWV LICENSE NUMBER