Provider Demographics
NPI:1417558420
Name:BOERNE REGEN AND ANTI-AGING CENTER, PLLC
Entity Type:Organization
Organization Name:BOERNE REGEN AND ANTI-AGING CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:DC, APRN, FNP-BC
Authorized Official - Phone:956-763-7767
Mailing Address - Street 1:29630 DOUBLE EAGLE CIR
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS RANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78015-4934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 REED RD
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-8605
Practice Address - Country:US
Practice Address - Phone:210-884-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty