Healthcare Provider Details

I. General information

NPI: 1144624321
Provider Name (Legal Business Name): REGENERATIVE SPINE AND BODY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 JACKSON AVE SUITE C
SATELLITE BEACH FL
32937-2993
US

IV. Provider business mailing address

155 JACKSON AVE SUITE C
SATELLITE BEACH FL
32937-2993
US

V. Phone/Fax

Practice location:
  • Phone: 321-777-3677
  • Fax: 321-779-8344
Mailing address:
  • Phone: 321-777-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL VILLE
Title or Position: OWNER
Credential: D.C.
Phone: 321-777-3677