Organization
REJUVENTA MEDICAL CORP.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GUITO C WINGFIELD M.D. (PRESIDENT)
(917) 494-1002
Entity
Organization
Contact information
Practice address
1755 KRESKY AVE., CENTRALIA, WA 98531
(360) 669-0098
(360) 669-0121
Mailing address
1755 KRESKY AVE. BOX 16, CENTRALIA, WA 98531
(360) 669-0098
(360) 669-0121
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1013550987
—
WA
01
—
1699792242
NPI
WA
01
—
MD00048810
WASHINGTON STATE MEDICAL LICENSE
WA
Enumeration date
10/23/2019
Last updated
10/17/2023
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