Healthcare Provider Details

I. General information

NPI: 1548844343
Provider Name (Legal Business Name): REGENCY SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14725 W MOUNTAIN VIEW BLVD
SURPRISE AZ
85374-2704
US

IV. Provider business mailing address

10240 W INDIAN SCHOOL RD STE 115
PHOENIX AZ
85037-5905
US

V. Phone/Fax

Practice location:
  • Phone: 623-243-9077
  • Fax:
Mailing address:
  • Phone: 623-243-9077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASON LEE MUSSMAN
Title or Position: OWNER
Credential: MD
Phone: 623-243-9077