Healthcare Provider Details

I. General information

NPI: 1508457532
Provider Name (Legal Business Name): REJUVENX OF BRADENTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 MANATEE AVE W STE A
BRADENTON FL
34205-4242
US

IV. Provider business mailing address

1470B ROYAL PALM BEACH BLVD
ROYAL PALM BEACH FL
33411-1608
US

V. Phone/Fax

Practice location:
  • Phone: 561-422-1819
  • Fax:
Mailing address:
  • Phone: 561-422-1819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY DECANIO
Title or Position: OWNER
Credential: DC
Phone: 561-422-1819