1689142622 NPI number — REGENESPINE, LLC

Table of content: (NPI 1689142622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689142622 NPI number — REGENESPINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
REGENESPINE, 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:
1689142622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 WHITEHORSE MERCERVILLE RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCERVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08619-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-570-6980
Provider Business Mailing Address Fax Number:
609-228-5060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 WHITEHORSE MERCERVILLE RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCERVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08619-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-439-7761
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROMAN
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
609-570-6980

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0111953 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".