Provider Demographics
NPI:1578928867
Name:REGENERATIVE MEDICAL GROUP
Entity Type:Organization
Organization Name:REGENERATIVE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-981-8058
Mailing Address - Street 1:600 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1605
Mailing Address - Country:US
Mailing Address - Phone:714-639-4012
Mailing Address - Fax:
Practice Address - Street 1:1400 SE GOLDTREE DR
Practice Address - Street 2:STE 207
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7582
Practice Address - Country:US
Practice Address - Phone:772-777-2836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA035817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIG494AMedicare UPIN