Healthcare Provider Details

I. General information

NPI: 1437848967
Provider Name (Legal Business Name): REGENERATE PHYSICAL THERAPY AND PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13337 TINING DR
POWAY CA
92064-1220
US

IV. Provider business mailing address

1401 21ST ST STE R
SACRAMENTO CA
95811-5226
US

V. Phone/Fax

Practice location:
  • Phone: 920-941-0136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL MORTIMER
Title or Position: CEO/OWNER
Credential:
Phone: 920-941-0136