MEDICARE: REGENERATE PHYSICAL THERAPY & PERFORMANCE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1659107449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENERATE PHYSICAL THERAPY & PERFORMANCE LLC

Provider Business Mailing Address
First Line	:	515 HAWTHORNE LN
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2911
Country	:	US
Telephone Number	:	269-449-7455
Fax Number	:

Provider Business Practice Location Address
First Line	:	8750 W CAMPUS CIRCLE DR ROOM 167
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49104-0001
Country	:	US
Telephone Number	:	269-235-9816
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPY
Name	:	PHILIP JARDINE
Credential	:	DPT
Telephone Number	:	269-235-9816

Provider Enumeration Date	:	09/10/2024
Last Update Date	:	09/10/2024

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