Provider Demographics
NPI:1174105035
Name:MODERN REJUVENATION CENTER, LLC
Entity type:Organization
Organization Name:MODERN REJUVENATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SENAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-827-6326
Mailing Address - Street 1:11495 N PENN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-6200
Mailing Address - Country:US
Mailing Address - Phone:317-827-6326
Mailing Address - Fax:317-827-6328
Practice Address - Street 1:11495 N PENN ST STE 100
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6200
Practice Address - Country:US
Practice Address - Phone:317-827-6326
Practice Address - Fax:317-827-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty