Provider Demographics
NPI:1740872944
Name:PUYALLUP REGENERATIVE MEDICINE, PLLC
Entity type:Organization
Organization Name:PUYALLUP REGENERATIVE MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-332-3628
Mailing Address - Street 1:PO BOX 1272
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0250
Mailing Address - Country:US
Mailing Address - Phone:253-841-4425
Mailing Address - Fax:253-445-5712
Practice Address - Street 1:1410 S MERIDIAN STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-6902
Practice Address - Country:US
Practice Address - Phone:253-841-4425
Practice Address - Fax:253-445-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty