Healthcare Provider Details

I. General information

NPI: 1528707585
Provider Name (Legal Business Name): BAY REJUVENATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2022
Last Update Date: 05/29/2022
Certification Date: 05/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 REESE ST
BAY SAINT LOUIS MS
39520-2823
US

IV. Provider business mailing address

309 REESE ST
BAY SAINT LOUIS MS
39520-2823
US

V. Phone/Fax

Practice location:
  • Phone: 662-571-0916
  • Fax:
Mailing address:
  • Phone: 662-571-0916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALISA STEPHENS
Title or Position: FAMILY NURSE PRACTITIONER
Credential: NP-C
Phone: 662-571-0916