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General NPI Number Information
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NPI Number | 1578928867
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Entity Type | Organization
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Legal Business Name | REGENERATIVE MEDICAL GROUP
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Dates
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Enumeration Date | 12/31/2015
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Last Update Date | 12/31/2015
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Provider Practice Location Address
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Address Line | 1400 SE GOLDTREE DR STE 207
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34952-7582
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Country | US
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Telephone | 772-777-2836
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Fax |
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Provider Business Mailing Address
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Address Line | 600 E CHAPMAN AVE
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City | ORANGE
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State | CA
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Zip | 92866-1605
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Country | US
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Telephone | 714-639-4012
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. BRYN J HENDERSON
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Credential | D.O
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Telephone | 714-981-8058
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 035817
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License Number State | CA
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