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General NPI Number Information
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NPI Number | 1629443643
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Entity Type | Organization
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Legal Business Name | REJUVA MED
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Dates
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Enumeration Date | 12/02/2015
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Last Update Date | 12/02/2015
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Provider Practice Location Address
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Address Line | 28945 STATE ROAD 54 SUITE 101
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543
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Country | US
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Telephone | 813-907-0950
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Fax | 813-907-7949
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Provider Business Mailing Address
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Address Line | 28945 STATE ROAD 54 SUITE 101
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543
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Country | US
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Telephone | 813-907-0950
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Fax | 813-907-7949
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENNETH ANDRONICO
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Credential | D.O.
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Telephone | 813-907-0950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OS004967
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License Number State | FL
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