Provider Demographics
NPI:1831475797
Name:REGENERATIONS CANCER WELLNESS FOUNDATION
Entity Type:Organization
Organization Name:REGENERATIONS CANCER WELLNESS FOUNDATION
Other - Org Name:REGENERATIONS WELLNESS CANCER FOUNDATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:STARR
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSON CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:MFT, CES, MFT,
Authorized Official - Phone:209-827-1960
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:1032 KEIKO STREET
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-0186
Mailing Address - Country:US
Mailing Address - Phone:209-827-1960
Mailing Address - Fax:
Practice Address - Street 1:1032 KEIKO ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-5213
Practice Address - Country:US
Practice Address - Phone:209-827-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X, 251300000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No251300000XAgenciesLocal Education Agency (LEA)
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty