Provider Demographics
NPI:1245541069
Name:REJUVENATING LIVES LLC
Entity type:Organization
Organization Name:REJUVENATING LIVES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBONIE
Authorized Official - Middle Name:KURTINA-JIMEKE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-916-8100
Mailing Address - Street 1:4913 PROFESSIONAL CT STE 202
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-1926
Mailing Address - Country:US
Mailing Address - Phone:919-916-8100
Mailing Address - Fax:984-377-4381
Practice Address - Street 1:4913 PROFESSIONAL CT STE 202
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-1926
Practice Address - Country:US
Practice Address - Phone:919-907-3512
Practice Address - Fax:984-377-4381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 251C00000X, 251S00000X, 106E00000X, 106S00000X, 253Z00000X, 343900000X, 385HR2055X, 385HR2060X
NCHC4151305S00000X, 385H00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No305S00000XManaged Care OrganizationsPoint of Service
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6602070Medicaid