Healthcare Provider Details

I. General information

NPI: 1366711624
Provider Name (Legal Business Name): REBOOT CENTER FOR INNOVATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5548 MYRTLE AVE SUITE 202
FREELAND WA
98249-8776
US

IV. Provider business mailing address

PO BOX 554
FREELAND WA
98249-0554
US

V. Phone/Fax

Practice location:
  • Phone: 360-331-2464
  • Fax: 866-277-7173
Mailing address:
  • Phone: 360-331-2464
  • Fax: 866-277-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberNT00001312
License Number StateWA

VIII. Authorized Official

Name: DR. JENNIFER V SCHIAVONE-RUTHENSTEINER
Title or Position: OWNER/MANAGER
Credential: N.D.
Phone: 360-331-2464