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General NPI Number Information
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NPI Number | 1104186667
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Entity Type | Organization
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Legal Business Name | REJUV INTEGRATIVE MEDICAL PRACTICE SHAWN C SNIDER
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Dates
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Enumeration Date | 05/17/2012
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Last Update Date | 05/17/2012
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Provider Practice Location Address
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Address Line | 405 N HERSHEY RD
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City | BLOOMINGTON
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State | IL
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Zip | 61704-3527
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Country | US
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Telephone | 309-622-3002
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Fax | 309-263-4611
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Provider Business Mailing Address
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Address Line | 405 N HERSHEY RD
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City | BLOOMINGTON
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State | IL
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Zip | 61704-3527
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Country | US
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Telephone | 309-622-3002
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Fax | 309-263-4611
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Authorized Official
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Title or Position | OWNER
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Name | MR. SHAWN CHRISTOPHER SNIDER
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Credential | CNP
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Telephone | 309-622-3002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 036.110856
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License Number State | IL
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