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General NPI Number Information
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NPI Number | 1679093546
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Entity Type | Organization
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Legal Business Name | REJUVENATION MEDICINE LLC
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Dates
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Enumeration Date | 06/22/2017
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Last Update Date | 07/11/2017
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Provider Practice Location Address
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Address Line | 830 GARRISON AVE
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City | TEANECK
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State | NJ
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Zip | 07666-2542
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Country | US
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Telephone | 201-785-7997
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Fax | 201-962-3878
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Provider Business Mailing Address
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Address Line | 19 PARSONS CT
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City | MAHWAH
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State | NJ
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Zip | 07430-2018
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GRACE CANDELARIO
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Credential | MD
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Telephone | 201-962-3878
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RX0202X
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Taxonomy Name | Medical Oncology Physician
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License Number | 25MA09608700
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License Number State | NJ
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