Provider Demographics
NPI:1902554009
Name:REJUVENATE AESTHETICS AND WELLNESS, LLC
Entity Type:Organization
Organization Name:REJUVENATE AESTHETICS AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LIZ
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:508-826-9408
Mailing Address - Street 1:6 BOYDEN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01570-2813
Mailing Address - Country:US
Mailing Address - Phone:508-826-9408
Mailing Address - Fax:
Practice Address - Street 1:6 BOYDEN STREET EXT
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-2813
Practice Address - Country:US
Practice Address - Phone:508-826-9408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service