Healthcare Provider Details

I. General information

NPI: 1396507984
Provider Name (Legal Business Name): BETWEEN THE LINES REJUVENATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1785 E WILSON AVE
SALT LAKE CITY UT
84108-2916
US

IV. Provider business mailing address

612 CORPORATE WAY STE 2M
VALLEY COTTAGE NY
10989-2027
US

V. Phone/Fax

Practice location:
  • Phone: 877-258-6331
  • Fax: 718-362-1651
Mailing address:
  • Phone: 718-362-1411
  • Fax: 718-362-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KRISTA CORBETT
Title or Position: OWNER
Credential: NP
Phone: 801-694-1197