Provider Demographics
NPI:1598252090
Name:REGENERATIVE SPORT SPINE AND SPA
Entity Type:Organization
Organization Name:REGENERATIVE SPORT SPINE AND SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PALLAVI
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHERUKUPALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-730-5600
Mailing Address - Street 1:10920 MOSS PARK RD STE 218
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-6087
Mailing Address - Country:US
Mailing Address - Phone:407-730-5600
Mailing Address - Fax:
Practice Address - Street 1:10920 MOSS PARK RD STE 218
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6087
Practice Address - Country:US
Practice Address - Phone:407-730-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127634261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty