Provider Demographics
NPI:1831766138
Name:JOINT REGENERATION GROUP
Entity type:Organization
Organization Name:JOINT REGENERATION GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BANNISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-864-8423
Mailing Address - Street 1:9000 WATSON BLVD APT 1103
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-3797
Mailing Address - Country:US
Mailing Address - Phone:770-864-8423
Mailing Address - Fax:
Practice Address - Street 1:104 WHITING WAY # 210-220
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8054
Practice Address - Country:US
Practice Address - Phone:478-333-1346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty