MEDICARE: MIND 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1811527518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND REJUVENATION, LLC.

Provider Business Mailing Address
First Line	:	7307 S YALE AVE STE 200
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-7049
Country	:	US
Telephone Number	:	918-392-4550
Fax Number	:	918-392-4551

Provider Business Practice Location Address
First Line	:	4922 E 73RD ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-7007
Country	:	US
Telephone Number	:	918-392-4550
Fax Number	:	918-392-4551

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. IFTIKHAR HUSSAIN
Credential	:	MD
Telephone Number	:	918-392-4550

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/09/2025

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