Provider Demographics
NPI:1548804800
Name:MESA REGEN GROUP, LLC
Entity Type:Organization
Organization Name:MESA REGEN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:PRUNI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-200-7846
Mailing Address - Street 1:5233 E SOUTHERN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3628
Mailing Address - Country:US
Mailing Address - Phone:480-830-2882
Mailing Address - Fax:480-830-2881
Practice Address - Street 1:5233 E SOUTHERN AVE STE 103
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3628
Practice Address - Country:US
Practice Address - Phone:480-830-2882
Practice Address - Fax:480-830-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty