Provider Demographics
NPI:1518532217
Name:SOUTHEAST CENTER FOR REGENERATIVE WOUND CARE PC
Entity Type:Organization
Organization Name:SOUTHEAST CENTER FOR REGENERATIVE WOUND CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-718-5380
Mailing Address - Street 1:1334 MACKEY BRANCH DR STE 104
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3471
Mailing Address - Country:US
Mailing Address - Phone:423-296-2604
Mailing Address - Fax:423-296-2607
Practice Address - Street 1:1334 MACKEY BRANCH DR STE 104
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3471
Practice Address - Country:US
Practice Address - Phone:423-296-2604
Practice Address - Fax:423-296-2607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty