Provider Demographics
NPI:1235429994
Name:REGENERATION ADULT LIFE CENTER
Entity Type:Organization
Organization Name:REGENERATION ADULT LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:BSHA
Authorized Official - Phone:706-315-2218
Mailing Address - Street 1:6197 TRESTLEWOOD DR
Mailing Address - Street 2:A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2949
Mailing Address - Country:US
Mailing Address - Phone:706-315-2218
Mailing Address - Fax:
Practice Address - Street 1:800 BROWN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3647
Practice Address - Country:US
Practice Address - Phone:706-315-2218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care