Healthcare Provider Details

I. General information

NPI: 1487270831
Provider Name (Legal Business Name): REGENERATIVE MEDICINE SPACE COAST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 02/10/2024
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W EAU GALLIE BLVD STE 101
MELBOURNE FL
32934-3285
US

IV. Provider business mailing address

PO BOX 24556
JACKSONVILLE FL
32241-4556
US

V. Phone/Fax

Practice location:
  • Phone: 321-323-3618
  • Fax:
Mailing address:
  • Phone: 786-370-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: RAFAEL FOSS
Title or Position: OWNER
Credential: DC
Phone: 786-370-1111