Provider Demographics
NPI:1306165832
Name:REJUVENANCE THERAPY LLC
Entity type:Organization
Organization Name:REJUVENANCE THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:W
Authorized Official - Last Name:DIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:360-601-7485
Mailing Address - Street 1:14504 NW 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-8006
Mailing Address - Country:US
Mailing Address - Phone:360-601-7485
Mailing Address - Fax:503-597-5324
Practice Address - Street 1:14201 NE 20TH AVE
Practice Address - Street 2:SUITE 1102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6410
Practice Address - Country:US
Practice Address - Phone:360-882-7373
Practice Address - Fax:360-882-7673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty