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General NPI Number Information
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NPI Number | 1356601629
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Entity Type | Organization
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Legal Business Name | REJUV CHAMPAIGN PC
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Dates
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Enumeration Date | 05/21/2012
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Last Update Date | 05/21/2012
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Provider Practice Location Address
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Address Line | 606 NORTH COUNTY FAIR DRIVE A
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City | CHAMPAIGN
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State | IL
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Zip | 61820
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Country | US
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Telephone | 217-607-0762
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Fax |
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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 | 309-662-3002
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHAWN CHRISTOPHER SNIDER
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Credential | CNP
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Telephone | 309-678-4243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 209005824
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License Number State | IL
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