=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063137271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED REJUVENATION THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2022
-----------------------------------------------------
Last Update Date | 08/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 CHURCH HILL RD BLDG E
-----------------------------------------------------
City | NEWTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06470-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-491-2999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 CHURCH HILL RD BLDG E
-----------------------------------------------------
City | NEWTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06470-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-491-2999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFCIAL
-----------------------------------------------------
Name | GARY GAROFALO
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 203-309-9378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------