Healthcare Provider Details

I. General information

NPI: 1992941363
Provider Name (Legal Business Name): REJUVENATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2009
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 HUNTSVILLE RD
EUREKA SPRINGS AR
72632-9730
US

IV. Provider business mailing address

1375 COUNTY ROAD 717
BERRYVILLE AR
72616-4462
US

V. Phone/Fax

Practice location:
  • Phone: 870-438-5676
  • Fax: 870-438-5469
Mailing address:
  • Phone: 870-438-5676
  • Fax: 870-438-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: PURMEALIA ALLEN
Title or Position: OWNER
Credential:
Phone: 870-438-5676