Provider Demographics
NPI:1467052431
Name:ATLANTA REGENERATIVE HEALTHCARE LLC
Entity Type:Organization
Organization Name:ATLANTA REGENERATIVE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:JUTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-730-6240
Mailing Address - Street 1:2133 HIGHWAY 317 STE 12318
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2648
Mailing Address - Country:US
Mailing Address - Phone:678-730-6240
Mailing Address - Fax:
Practice Address - Street 1:2445 MOON RD STE 4
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7851
Practice Address - Country:US
Practice Address - Phone:678-985-7286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty