Healthcare Provider Details

I. General information

NPI: 1649802497
Provider Name (Legal Business Name): REGENERATIVE HEALTH 360 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 SKYLYN DR STE 420
SPARTANBURG SC
29307-1086
US

IV. Provider business mailing address

1650 SKYLYN DR STE 420
SPARTANBURG SC
29307-1047
US

V. Phone/Fax

Practice location:
  • Phone: 864-208-9138
  • Fax: 864-308-8325
Mailing address:
  • Phone: 864-464-7985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHERYL RIVERS
Title or Position: CFO
Credential:
Phone: 864-606-7764