Healthcare Provider Details

I. General information

NPI: 1669245171
Provider Name (Legal Business Name): REGENERATIVE ORTHOPEDIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15755 SW SEQUOIA PKWY STE 200
TIGARD OR
97224-7166
US

IV. Provider business mailing address

7111 SW NYBERG ST STE 100
TUALATIN OR
97062-6245
US

V. Phone/Fax

Practice location:
  • Phone: 503-656-0836
  • Fax: 503-656-9464
Mailing address:
  • Phone: 503-656-0836
  • Fax: 503-656-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMANDA KOENIG
Title or Position: COO
Credential:
Phone: 503-905-4102