=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629213814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REJUVANATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2008
-----------------------------------------------------
Last Update Date | 12/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 CURRENCY DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-9398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-678-4243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 CURRENCY DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-9398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CNP
-----------------------------------------------------
Name | MR. SHAWN C SNIDER
-----------------------------------------------------
Credential | MSN
-----------------------------------------------------
Telephone | 309-278-0566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209005824
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------