Provider Demographics
NPI:1003572827
Name:REGENERATIVE INSTITUTE OF WELLESLEY PC
Entity Type:Organization
Organization Name:REGENERATIVE INSTITUTE OF WELLESLEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-489-5427
Mailing Address - Street 1:422 WORCESTER ST STE 303
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5341
Mailing Address - Country:US
Mailing Address - Phone:781-489-5427
Mailing Address - Fax:
Practice Address - Street 1:422 WORCESTER ST STE 303
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-5341
Practice Address - Country:US
Practice Address - Phone:781-489-5427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty