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General NPI Number Information
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NPI Number | 1891076741
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Entity Type | Organization
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Legal Business Name | REJUVENATE BODYWORKS, PL
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Dates
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Enumeration Date | 09/06/2011
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Last Update Date | 09/06/2011
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Provider Practice Location Address
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Address Line | 112 E PINE ST
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City | LAKELAND
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State | FL
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Zip | 33801-4965
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Country | US
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Telephone | 863-397-7531
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Fax |
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Provider Business Mailing Address
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Address Line | 11919 BACKLAND PATH RD
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City | POLK CITY
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State | FL
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Zip | 33868-2604
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Country | US
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Telephone | 863-397-7531
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. LEAH M STINE
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Credential | LMT
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Telephone | 863-397-7531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA34453
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License Number State | FL
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