Provider Demographics
NPI:1306016282
Name:ETHOS REGENERATIVE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ETHOS REGENERATIVE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CORY
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-409-0016
Mailing Address - Street 1:300 E. ROYAL LN
Mailing Address - Street 2:SUITE 110
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039
Mailing Address - Country:US
Mailing Address - Phone:972-409-0016
Mailing Address - Fax:972-409-0013
Practice Address - Street 1:300 E. ROYAL LN
Practice Address - Street 2:SUITE 110
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039
Practice Address - Country:US
Practice Address - Phone:972-409-0016
Practice Address - Fax:972-409-0013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8277111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU 75768Medicare UPIN