Healthcare Provider Details

I. General information

NPI: 1093284671
Provider Name (Legal Business Name): EXODUS REGENERATIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/30/2025
Certification Date: 11/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 EASTPARK DR STE 102
BRENTWOOD TN
37027-7535
US

IV. Provider business mailing address

104 EASTPARK DR STE 102
BRENTWOOD TN
37027-7535
US

V. Phone/Fax

Practice location:
  • Phone: 615-445-7701
  • Fax: 615-445-7771
Mailing address:
  • Phone: 615-445-7701
  • Fax: 615-445-7771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN KYLE ARD
Title or Position: OWNER
Credential: DC
Phone: 615-445-7701