Provider Demographics
NPI:1285145961
Name:REJUVENATION HOME HEALTH CARE, LLC
Entity type:Organization
Organization Name:REJUVENATION HOME HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEVELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-240-4591
Mailing Address - Street 1:1409 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1905
Mailing Address - Country:US
Mailing Address - Phone:314-240-4591
Mailing Address - Fax:314-288-0147
Practice Address - Street 1:1409 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1905
Practice Address - Country:US
Practice Address - Phone:314-240-4591
Practice Address - Fax:314-288-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========Medicaid