Provider Demographics
NPI:1629555172
Name:WEST GEORGIA REGENERATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:WEST GEORGIA REGENERATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANIOTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:762-204-4103
Mailing Address - Street 1:3624 EDGEWOOD RD STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-8238
Mailing Address - Country:US
Mailing Address - Phone:762-204-4103
Mailing Address - Fax:
Practice Address - Street 1:3624 EDGEWOOD RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907
Practice Address - Country:US
Practice Address - Phone:762-204-4103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty