Healthcare Provider Details

I. General information

NPI: 1659670917
Provider Name (Legal Business Name): REJUVENIX MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22635 ALESSANDRO BLVD SUITE B
MORENO VALLEY CA
92553-8550
US

IV. Provider business mailing address

22635 ALESSANDRO BLVD SUITE B
MORENO VALLEY CA
92553-8550
US

V. Phone/Fax

Practice location:
  • Phone: 951-653-5300
  • Fax: 951-653-5346
Mailing address:
  • Phone: 951-653-5300
  • Fax: 951-653-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225B00000X
TaxonomyPulmonary Function Technologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2278P1004X
TaxonomyPulmonary Diagnostics Certified Respiratory Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SANTIAGO ALVAREZ
Title or Position: DIRECTOR
Credential:
Phone: 951-653-5300