Healthcare Provider Details

I. General information

NPI: 1598252090
Provider Name (Legal Business Name): REGENERATIVE SPORT SPINE AND SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10920 MOSS PARK RD STE 218
ORLANDO FL
32832-6087
US

IV. Provider business mailing address

10920 MOSS PARK RD STE 218
ORLANDO FL
32832-6087
US

V. Phone/Fax

Practice location:
  • Phone: 407-730-5600
  • Fax:
Mailing address:
  • Phone: 407-730-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME127634
License Number StateFL

VIII. Authorized Official

Name: PALLAVI R. CHERUKUPALLY
Title or Position: OWNER
Credential: MD
Phone: 407-730-5600