=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013550987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REJUVENTA MEDICAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2019
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1755 KRESKY AVE.
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-669-0098
-----------------------------------------------------
Fax | 360-669-0121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1755 KRESKY AVE. BOX 16
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-669-0098
-----------------------------------------------------
Fax | 360-669-0121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GUITO C WINGFIELD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 917-494-1002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------