Healthcare Provider Details

I. General information

NPI: 1912596990
Provider Name (Legal Business Name): REGENERATIVE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 SANTA BARBARA BLVD STE A
LADY LAKE FL
32159-6820
US

IV. Provider business mailing address

1585 SANTA BARBARA BLVD STE A
LADY LAKE FL
32159-6820
US

V. Phone/Fax

Practice location:
  • Phone: 352-430-2121
  • Fax: 352-430-2114
Mailing address:
  • Phone: 352-430-2121
  • Fax: 352-430-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTIN WULFF
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 352-430-2121