=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619397247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REJUVENATION WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2014
-----------------------------------------------------
Last Update Date | 04/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2704 20TH STREET SOUTH SUITE 104
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-413-8599
-----------------------------------------------------
Fax | 205-383-2425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2704 20TH STREET SOUTH SUITE 104
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-413-8599
-----------------------------------------------------
Fax | 205-383-2425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEDICAL DIRECTOR
-----------------------------------------------------
Name | FARAH TAJ SULTAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 205-413-8599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | AL24915
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------