1447006663 NPI number — REGENERATION GROVE PSYCHIATRY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447006663 NPI number — REGENERATION GROVE PSYCHIATRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGENERATION GROVE PSYCHIATRY 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:
1447006663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
865 E BASELINE RD # 1098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85233-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-618-0323
Provider Business Mailing Address Fax Number:
480-605-2773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1038 W PECOS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85210-8238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-618-0323
Provider Business Practice Location Address Fax Number:
480-605-2773
Provider Enumeration Date:
04/29/2024

Additional Information

Authorized Official

Authorized Official Last Name:
GROVES
Authorized Official First Name:
LLEVA
Authorized Official Middle Name:
Authorized Official Title or Position:
PMHNP-BC
Authorized Official Telephone Number:
480-618-0323

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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