Healthcare Provider Details

I. General information

NPI: 1164043204
Provider Name (Legal Business Name): ORTHOPAEDIC REGENERATIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 S LAKESHORE DR
TEMPE AZ
85282-7197
US

IV. Provider business mailing address

4400 N SCOTTSDALE RD # 9-844
SCOTTSDALE AZ
85251-3331
US

V. Phone/Fax

Practice location:
  • Phone: 602-429-0404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELO MATTALINO
Title or Position: OWNER
Credential: MD
Phone: 602-429-0404