Provider Demographics
NPI:1093284671
Name:EXODUS REGENERATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:EXODUS REGENERATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:ARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-445-7701
Mailing Address - Street 1:2652 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2538
Mailing Address - Country:US
Mailing Address - Phone:812-949-2273
Mailing Address - Fax:812-941-3110
Practice Address - Street 1:2652 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2538
Practice Address - Country:US
Practice Address - Phone:812-949-2273
Practice Address - Fax:812-941-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08002814AOtherCHIROPRACTOR