1609418086 NPI number — MEMPHIS REGENERATIVE HEALTHCARE LLC

Table of content: (NPI 1609418086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609418086 NPI number — MEMPHIS REGENERATIVE HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMPHIS REGENERATIVE HEALTHCARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609418086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7981 DEXTER RD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORDOVA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38016-8798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-237-0484
Provider Business Mailing Address Fax Number:
901-794-0854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7981 DEXTER RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORDOVA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38016-8798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-237-0484
Provider Business Practice Location Address Fax Number:
901-794-0854
Provider Enumeration Date:
10/17/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
901-237-0484

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1147 . This is a "TN LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".