MEDICARE: JOINT REJUVENATION CENTER, PLLC

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	2086S0122X	Plastic and Reconstructive Surgery Physician	J4553	TX

General Provider Information

NPI Number	:	1982111399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOINT REJUVENATION CENTER, PLLC

Provider Business Mailing Address
First Line	:	2724 YALE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-2120
Country	:	US
Telephone Number	:	713-706-6143
Fax Number	:	832-409-3169

Provider Business Practice Location Address
First Line	:	2724 YALE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-2120
Country	:	US
Telephone Number	:	713-706-6143
Fax Number	:	832-409-3169

Authorized Official
Title or Position	:	OPERATIONS
Name	:	JOSHUA ERICKSON
Credential	:
Telephone Number	:	832-212-7547

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	01/08/2018

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