Healthcare Provider Details

I. General information

NPI: 1831475797
Provider Name (Legal Business Name): REGENERATIONS CANCER WELLNESS FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 KEIKO ST
LOS BANOS CA
93635-5213
US

IV. Provider business mailing address

PO BOX 186 1032 KEIKO STREET
LOS BANOS CA
93635-0186
US

V. Phone/Fax

Practice location:
  • Phone: 209-827-1960
  • Fax:
Mailing address:
  • Phone: 209-827-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. STARR CARSON CLEARY
Title or Position: PRESIDENT
Credential: MFT, CES, MFT,
Phone: 209-827-1960