Basic Information
| Provider Information | |||||||||
| NPI: | 1568025419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REINVENTME, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 SANTA BARBARA BLVD | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523534212 | ||||||||
| FaxNumber: | 3523885068 | ||||||||
| Practice Location | |||||||||
| Address1: | 13696 N US HIGHWAY 441 STE 100 | ||||||||
| Address2: | |||||||||
| City: | LADY LAKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887200989 | ||||||||
| FaxNumber: | 4079443503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | KHANNA | ||||||||
| AuthorizedOfficialFirstName: | TRISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8887200989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | MEDICARE | OTHER |