Provider Demographics
NPI:1285200584
Name:REGENERATION PSYCHIATRY
Entity Type:Organization
Organization Name:REGENERATION PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOBERT
Authorized Official - Middle Name:BALLESTEROS
Authorized Official - Last Name:POBLETE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-277-2899
Mailing Address - Street 1:2512 ARTESIA BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3274
Mailing Address - Country:US
Mailing Address - Phone:424-277-2899
Mailing Address - Fax:424-277-2899
Practice Address - Street 1:2512 ARTESIA BLVD STE 310
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3274
Practice Address - Country:US
Practice Address - Phone:424-277-2899
Practice Address - Fax:424-277-2899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty