MEDICARE: BETWEEN THE LINES REJUVENATION LLC

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	253Z00000X	In Home Supportive Care Agency
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1396507984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETWEEN THE LINES REJUVENATION LLC

Provider Business Mailing Address
First Line	:	612 CORPORATE WAY STE 2M
Second Line	:
City	:	VALLEY COTTAGE
State	:	NY
Zip	:	10989-2027
Country	:	US
Telephone Number	:	718-362-1411
Fax Number	:	718-362-1651

Provider Business Practice Location Address
First Line	:	1785 E WILSON AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2916
Country	:	US
Telephone Number	:	877-258-6331
Fax Number	:	718-362-1651

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTA CORBETT
Credential	:	NP
Telephone Number	:	801-694-1197

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	07/17/2024

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