Provider Demographics
NPI:1144736471
Name:REGENERATIVE MEDICAL GROUP FLORIDA
Entity Type:Organization
Organization Name:REGENERATIVE MEDICAL GROUP FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:WHITELEY
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:772-207-7534
Mailing Address - Street 1:1400 SE GOLDTREE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7582
Mailing Address - Country:US
Mailing Address - Phone:772-207-7534
Mailing Address - Fax:772-777-2837
Practice Address - Street 1:1400 SE GOLDTREE DR STE 105
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7582
Practice Address - Country:US
Practice Address - Phone:772-207-7534
Practice Address - Fax:772-777-2837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty