MEDICARE: REJUVE-NATIONS OUTPATIENTS FACILITY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	370105AN	CA

General Provider Information

NPI Number	:	1043679095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REJUVE-NATIONS OUTPATIENTS FACILITY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 152841
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92195-2841
Country	:	US
Telephone Number	:	619-602-9405
Fax Number	:	951-657-7180

Provider Business Practice Location Address
First Line	:	4101 UNIVERSITY AVE
Second Line	:	STUITE E204, E205
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1418
Country	:	US
Telephone Number	:	619-602-9405
Fax Number	:	951-657-7180

Authorized Official
Title or Position	:	CEO
Name	:	MS. BRENDA LEONOR SQUARREL
Credential	:
Telephone Number	:	619-602-9405

Provider Enumeration Date	:	02/18/2016
Last Update Date	:	02/19/2016

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