Basic Information
| Provider Information | |||||||||
| NPI: | 1134752025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REJUV INTEGRATED MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1231 | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287131231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886933410 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Practice Location | |||||||||
| Address1: | 10210 HICKORYWOOD HILL AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280783417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042749084 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7042749084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02G96 | 01 | NC | BCBS NC | OTHER | DZ8771 | 01 | NC | RR MEDICARE | OTHER | 1134752025 | 05 | NC | MEDICAID | GD-18423957 | 01 | NC | UHC | OTHER | J931 | 01 | NC | MEDICARE PTAN | OTHER |