Provider Demographics
NPI:1679093546
Name:REJUVENATION MEDICINE LLC
Entity type:Organization
Organization Name:REJUVENATION MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDELARIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-962-3878
Mailing Address - Street 1:19 PARSONS CT
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-2018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 GARRISON AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-2542
Practice Address - Country:US
Practice Address - Phone:201-785-7997
Practice Address - Fax:201-962-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09608700207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty