Healthcare Provider Details

I. General information

NPI: 1629564463
Provider Name (Legal Business Name): OSTEOPATHIC REGENERATIVE MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 BISCAYNE BLVD STE 406
MIAMI FL
33137-3737
US

IV. Provider business mailing address

3915 BISCAYNE BLVD STE 406
MIAMI FL
33137-3737
US

V. Phone/Fax

Practice location:
  • Phone: 305-367-1176
  • Fax: 877-391-1611
Mailing address:
  • Phone: 305-367-1176
  • Fax: 877-391-1611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOS10979
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS10979
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberOS10979
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberOS10979
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberOS10979
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberOS10979
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateFL
# 11
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberOS10979
License Number StateFL

VIII. Authorized Official

Name: KRISTOPHER GODDARD
Title or Position: OWNDER
Credential: DO
Phone: 305-367-1176