Healthcare Provider Details

I. General information

NPI: 1306165832
Provider Name (Legal Business Name): REJUVENANCE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14201 NE 20TH AVE SUITE 1102
VANCOUVER WA
98686-6410
US

IV. Provider business mailing address

14504 NW 20TH AVE
VANCOUVER WA
98685-8006
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-7373
  • Fax: 360-882-7673
Mailing address:
  • Phone: 360-601-7485
  • Fax: 503-597-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00007729
License Number StateWA

VIII. Authorized Official

Name: MRS. SARAH W DIBLE
Title or Position: SOLE MEMBER
Credential: MSPT
Phone: 360-601-7485