=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386904845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REJUV ROLLING MEADOWS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2012
-----------------------------------------------------
Last Update Date | 05/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 ALGONQUIN RD
-----------------------------------------------------
City | ROLLING MEADOWS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60008-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-457-4378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 OAK VALLEY DR
-----------------------------------------------------
City | GOODFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61742-9502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-678-4243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAWN CHRISTOPHER SNIDER
-----------------------------------------------------
Credential | CNP
-----------------------------------------------------
Telephone | 309-678-4243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 036095342
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------