Healthcare Provider Details

I. General information

NPI: 1760929590
Provider Name (Legal Business Name): CENTER FOR REGENERATIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LATIGO LN STE E
CANON CITY CO
81212-8114
US

IV. Provider business mailing address

113 LATIGO LN
CANON CITY CO
81212-8114
US

V. Phone/Fax

Practice location:
  • Phone: 719-371-0000
  • Fax: 888-965-6893
Mailing address:
  • Phone: 719-371-0000
  • Fax: 888-965-6893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA KING
Title or Position: CMO
Credential: MD
Phone: 719-371-0000