Provider Demographics
NPI:1528348620
Name:PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP
Entity type:Organization
Organization Name:PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-610-9360
Mailing Address - Street 1:7230 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307
Mailing Address - Country:US
Mailing Address - Phone:818-518-5980
Mailing Address - Fax:818-337-2049
Practice Address - Street 1:7230 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 302
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307
Practice Address - Country:US
Practice Address - Phone:818-518-5980
Practice Address - Fax:818-337-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22296103T00000X
CADC24805111NN1001X
CAAC8403171100000X
CAPA17921363A00000X
CAG56249208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty