Healthcare Provider Details

I. General information

NPI: 1184085938
Provider Name (Legal Business Name): REGENERATIVE HEALTH AND WELLNESS MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S MAIN STREET
HOLLY CO
81047-0304
US

IV. Provider business mailing address

209 S. MAIN STREET
HOLLY CO
81047-0304
US

V. Phone/Fax

Practice location:
  • Phone: 719-537-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB HOLDREN
Title or Position: OWNER
Credential: DC
Phone: 719-537-0200