=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609408194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZ REGENERATIVE MEDICNE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2020
-----------------------------------------------------
Last Update Date | 02/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16620 N 40TH ST STE G2
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-992-2656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16620 N 40TH ST STE G2
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-992-2656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY WARD FROST
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 602-992-2656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------