Healthcare Provider Details

I. General information

NPI: 1235429994
Provider Name (Legal Business Name): REGENERATION ADULT LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BROWN AVE
COLUMBUS GA
31906-3647
US

IV. Provider business mailing address

6197 TRESTLEWOOD DR A
COLUMBUS GA
31909-2949
US

V. Phone/Fax

Practice location:
  • Phone: 706-315-2218
  • Fax:
Mailing address:
  • Phone: 706-315-2218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE WYNN
Title or Position: OWNER
Credential: BSHA
Phone: 706-315-2218