Provider Demographics
NPI:1366711624
Name:REBOOT CENTER FOR INNOVATIVE MEDICINE
Entity type:Organization
Organization Name:REBOOT CENTER FOR INNOVATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:V
Authorized Official - Last Name:SCHIAVONE-RUTHENSTEINER
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:360-331-2464
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-0554
Mailing Address - Country:US
Mailing Address - Phone:360-331-2464
Mailing Address - Fax:866-277-7173
Practice Address - Street 1:5548 MYRTLE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249-8776
Practice Address - Country:US
Practice Address - Phone:360-331-2464
Practice Address - Fax:866-277-7173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001312261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty