1962973156 NPI number — REGENERATIVE THERAPY OF GEORGIA

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 1962973156 NPI number — REGENERATIVE THERAPY OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGENERATIVE THERAPY OF GEORGIA
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:
1962973156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5132 PANOLA MILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30038-2351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-906-1316
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5040 SNAPFINGER WOODS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
STONECREST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-380-6560
Provider Business Practice Location Address Fax Number:
770-502-6745
Provider Enumeration Date:
12/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FULBRIGHT
Authorized Official First Name:
LAKENDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-906-1316

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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