Provider Demographics
NPI:1932948387
Name:RADIANT REJUVENATION WELLNESS
Entity type:Organization
Organization Name:RADIANT REJUVENATION WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-241-2915
Mailing Address - Street 1:4914 MCFARLAND DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2518
Mailing Address - Country:US
Mailing Address - Phone:571-241-2915
Mailing Address - Fax:
Practice Address - Street 1:4914 MCFARLAND DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-2518
Practice Address - Country:US
Practice Address - Phone:571-241-2915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty