Provider Demographics
NPI:1104337740
Name:SO CAL REGENERATIVE MEDICAL CLINICS INC
Entity type:Organization
Organization Name:SO CAL REGENERATIVE MEDICAL CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:626-965-2334
Mailing Address - Street 1:843 S STATE COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4613
Mailing Address - Country:US
Mailing Address - Phone:626-715-9820
Mailing Address - Fax:
Practice Address - Street 1:843 S STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-4613
Practice Address - Country:US
Practice Address - Phone:626-715-9820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty