Provider Demographics
NPI:1851911945
Name:REGEN 360 INDY LLC
Entity Type:Organization
Organization Name:REGEN 360 INDY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TORI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:817-915-9965
Mailing Address - Street 1:14251 LANGHAM DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46074-4401
Mailing Address - Country:US
Mailing Address - Phone:312-972-8307
Mailing Address - Fax:
Practice Address - Street 1:70 E 91ST ST STE 101
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1550
Practice Address - Country:US
Practice Address - Phone:312-972-8307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty