Healthcare Provider Details

I. General information

NPI: 1649734401
Provider Name (Legal Business Name): REGENESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 N 91ST ST STE A115
SCOTTSDALE AZ
85258-5036
US

IV. Provider business mailing address

1911 E OLIVE CT
GILBERT AZ
85234-8162
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-4949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BOZEMAN
Title or Position: CEO
Credential:
Phone: 505-870-4949