Healthcare Provider Details

I. General information

NPI: 1154822369
Provider Name (Legal Business Name): REGENERATIVE FOOT & ANKLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 N 94TH DR STE F1
PEORIA AZ
85381-4232
US

IV. Provider business mailing address

13660 N 94TH DR STE F1
PEORIA AZ
85381-4232
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-0522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVEN SHANE MOORE
Title or Position: MANAGER
Credential:
Phone: 623-974-0522