MEDICARE: REGENERATION PHYSICAL THERAPY 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	:	1679214605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENERATION PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	758 MAIN ST STE 120
Second Line	:
City	:	GARDENDALE
State	:	AL
Zip	:	35071-3021
Country	:	US
Telephone Number	:	205-401-6257
Fax Number	:

Provider Business Practice Location Address
First Line	:	758 MAIN ST STE 120
Second Line	:
City	:	GARDENDALE
State	:	AL
Zip	:	35071-3021
Country	:	US
Telephone Number	:	205-401-6257
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SOMMER SMITH
Credential	:	PT
Telephone Number	:	205-401-6257

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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