Healthcare Provider Details

I. General information

NPI: 1811506538
Provider Name (Legal Business Name): REGENERATE ATX PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 08/01/2020
Certification Date: 08/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11610 FM 2244 RD STE 230
AUSTIN TX
78738-5457
US

IV. Provider business mailing address

11610 FM 2244 RD STE 230
AUSTIN TX
78738-5457
US

V. Phone/Fax

Practice location:
  • Phone: 512-284-7025
  • Fax:
Mailing address:
  • Phone: 512-284-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN N HOGAN
Title or Position: OWNER
Credential: MD
Phone: 512-284-7025