1790346831 NPI number — WELLSPRING REGENERATIVE MEDICINE, LLC

Table of content: (NPI 1790346831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790346831 NPI number — WELLSPRING REGENERATIVE MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPRING REGENERATIVE MEDICINE, 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:
CENTRAL FLORIDA INJURY AND RECOVERY CENTER
Provider Other Organization Name Type Code:
3
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:
1790346831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2415 S VOLUSIA AVE STE A2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32763-7623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-775-6879
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
940 CENTRE CIR STE 1018
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32714-7242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-789-0600
Provider Business Practice Location Address Fax Number:
407-789-0601
Provider Enumeration Date:
06/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ROLLMAN
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
407-789-0600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 116355200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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