Healthcare Provider Details

I. General information

NPI: 1891435293
Provider Name (Legal Business Name): REJUVENESCENSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10357 IVY LAUREL CV
CORDOVA TN
38018-6685
US

IV. Provider business mailing address

10357 IVY LAUREL CV
CORDOVA TN
38018-6685
US

V. Phone/Fax

Practice location:
  • Phone: 901-930-6966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: LANORA OWENS
Title or Position: DIRECTOR
Credential:
Phone: 901-930-6966