Provider Demographics
NPI:1447712559
Name:REJUVENATION MEDICAL PLLC
Entity type:Organization
Organization Name:REJUVENATION MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRETCHMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-789-2639
Mailing Address - Street 1:20011 BALLINGER WAY NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1286
Mailing Address - Country:US
Mailing Address - Phone:206-407-4171
Mailing Address - Fax:
Practice Address - Street 1:20011 BALLINGER WAY NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1286
Practice Address - Country:US
Practice Address - Phone:206-407-4171
Practice Address - Fax:206-906-9981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOP60765453OtherLICENSE