Provider Demographics
NPI:1275047938
Name:REGENESISDOC LLC
Entity Type:Organization
Organization Name:REGENESISDOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MABO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-825-5757
Mailing Address - Street 1:2892 MOUNTAIN INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3014
Mailing Address - Country:US
Mailing Address - Phone:678-825-5757
Mailing Address - Fax:
Practice Address - Street 1:2892 MOUNTAIN INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3014
Practice Address - Country:US
Practice Address - Phone:678-825-5757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care