Healthcare Provider Details

I. General information

NPI: 1831766138
Provider Name (Legal Business Name): JOINT REGENERATION GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 09/14/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WHITING WAY # 210-220
WARNER ROBINS GA
31088-8054
US

IV. Provider business mailing address

9000 WATSON BLVD APT 1103
BYRON GA
31008-3797
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-1346
  • Fax:
Mailing address:
  • Phone: 770-864-8423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL E BANNISTER
Title or Position: OWNER
Credential:
Phone: 770-864-8423