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General NPI Number Information
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NPI Number | 1588166094
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Entity Type | Organization
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Legal Business Name | REVIVE REJUVENATION CENTER ANTI AGING REGENERATIVE CENTER INC
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Dates
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Enumeration Date | 03/01/2018
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Last Update Date | 03/21/2018
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Provider Practice Location Address
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Address Line | 7509 DRAPER AVE STE A
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City | LA JOLLA
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State | CA
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Zip | 92037-4857
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Country | US
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Telephone | 858-352-6200
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Fax | 858-362-7555
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Provider Business Mailing Address
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Address Line | 7509 DRAPER AVE
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City | LA JOLLA
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State | CA
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Zip | 92037-4862
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Country | US
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Telephone | 858-352-6200
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Fax | 858-362-7555
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | MICHELLE GUTIERREZ
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Credential |
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Telephone | 619-501-6278
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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 |
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License Number State |
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