=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518467059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGENESYS PHYSICAL MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 01/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 OLD NEWMAN RD STE 100
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75036-4773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-712-5556
-----------------------------------------------------
Fax | 972-712-5579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 OLD NEWMAN RD STE 100
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75036-4773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-712-5556
-----------------------------------------------------
Fax | 972-712-5579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRANDON B WILSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 972-712-5556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------