Healthcare Provider Details

I. General information

NPI: 1144693292
Provider Name (Legal Business Name): REGENESIS WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 VICKERS DR
COLORADO SPRINGS CO
80918-1981
US

IV. Provider business mailing address

2310 VICKERS DR
COLORADO SPRINGS CO
80918-1981
US

V. Phone/Fax

Practice location:
  • Phone: 719-428-5310
  • Fax: 720-504-0186
Mailing address:
  • Phone: 719-428-5310
  • Fax: 720-504-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0990332-NP
License Number StateCO

VIII. Authorized Official

Name: ANNA MARIA DOUGLAS
Title or Position: OWNER
Credential: FNP
Phone: 719-428-5310