Provider Demographics
NPI:1548732159
Name:REGENERATIVE MEDICAL GROUP INC
Entity type:Organization
Organization Name:REGENERATIVE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYN
Authorized Official - Middle Name:JARALD
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-639-4012
Mailing Address - Street 1:615 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1643
Mailing Address - Country:US
Mailing Address - Phone:714-639-4012
Mailing Address - Fax:
Practice Address - Street 1:2624 S
Practice Address - Street 2:US1
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982
Practice Address - Country:US
Practice Address - Phone:772-207-7534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENERATIVE MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty