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General NPI Number Information
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NPI Number | 1144693292
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Entity Type | Organization
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Legal Business Name | REGENESIS WELLNESS LLC
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Dates
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Enumeration Date | 11/10/2015
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Last Update Date | 04/18/2018
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Provider Practice Location Address
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Address Line | 2310 VICKERS DR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-1981
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Country | US
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Telephone | 719-428-5310
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Fax | 720-504-0186
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Provider Business Mailing Address
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Address Line | 2310 VICKERS DR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-1981
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Country | US
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Telephone | 719-428-5310
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Fax | 720-504-0186
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Authorized Official
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Title or Position | OWNER
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Name | ANNA MARIA DOUGLAS
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Credential | FNP
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Telephone | 719-428-5310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 0990332-NP
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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