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General NPI Number Information
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NPI Number | 1740583749
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Entity Type | Organization
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Legal Business Name | REJUVENATE MED SPA
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Dates
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Enumeration Date | 12/13/2010
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Last Update Date | 12/13/2010
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Provider Practice Location Address
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Address Line | 1111 BRICKELL AVE FL 11
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City | MIAMI
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State | FL
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Zip | 33131-3122
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Country | US
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Telephone | 954-925-8100
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Fax | 954-827-3913
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Provider Business Mailing Address
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Address Line | 1111 BRICKELL AVE FL 11
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City | MIAMI
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State | FL
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Zip | 33131-3122
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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 | PRESIDENT/MD
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Name | ALTAGRACIA MIRANDA
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Credential |
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Telephone | 954-925-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME87277
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License Number State | FL
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