Healthcare Provider Details

I. General information

NPI: 1558962415
Provider Name (Legal Business Name): REGENERATIVE MEDICINE OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 ELECTRON DR STE 101
LOUISVILLE KY
40299-3824
US

IV. Provider business mailing address

10900 ELECTRON DR STE 101
LOUISVILLE KY
40299-3824
US

V. Phone/Fax

Practice location:
  • Phone: 502-425-6200
  • Fax: 502-425-6400
Mailing address:
  • Phone: 502-425-6200
  • Fax: 502-425-6400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SHANE CUMMINS
Title or Position: OWNER
Credential:
Phone: 502-425-6200