Provider Demographics
NPI:1932161007
Name:REGENTOX LLC
Entity Type:Organization
Organization Name:REGENTOX LLC
Other - Org Name:MB LASER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THERRESA ANHDAO
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:QUACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-465-9599
Mailing Address - Street 1:9191 BOLSA AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5561
Mailing Address - Country:US
Mailing Address - Phone:714-622-4125
Mailing Address - Fax:714-622-4125
Practice Address - Street 1:9191 BOLSA AVE STE 207
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5561
Practice Address - Country:US
Practice Address - Phone:714-622-4125
Practice Address - Fax:714-622-4125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6261171100000X
174400000X, 208100000X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0062610OtherMEDI-CAL PROVIDER NUMBER