Healthcare Provider Details

I. General information

NPI: 1013550987
Provider Name (Legal Business Name): REJUVENTA MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 KRESKY AVE.
CENTRALIA WA
98531
US

IV. Provider business mailing address

1755 KRESKY AVE. BOX 16
CENTRALIA WA
98531
US

V. Phone/Fax

Practice location:
  • Phone: 360-669-0098
  • Fax: 360-669-0121
Mailing address:
  • Phone: 360-669-0098
  • Fax: 360-669-0121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GUITO C WINGFIELD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 917-494-1002