Provider Demographics
NPI:1164043204
Name:ORTHOPAEDIC REGENERATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:ORTHOPAEDIC REGENERATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTALINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-429-0404
Mailing Address - Street 1:4400 N SCOTTSDALE RD # 9-844
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4765 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7197
Practice Address - Country:US
Practice Address - Phone:602-429-0404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty