Provider Demographics
NPI:1386418184
Name:SOUTH SIDE REJUVENATION LLC
Entity type:Organization
Organization Name:SOUTH SIDE REJUVENATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELCHER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:708-670-2576
Mailing Address - Street 1:17749 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-4370
Mailing Address - Country:US
Mailing Address - Phone:708-670-2576
Mailing Address - Fax:
Practice Address - Street 1:17749 65TH AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-4370
Practice Address - Country:US
Practice Address - Phone:708-670-2576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty