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General NPI Number Information
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NPI Number | 1851911945
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Entity Type | Organization
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Legal Business Name | REGEN 360 INDY LLC
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Dates
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Enumeration Date | 04/20/2020
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Last Update Date | 04/20/2020
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Provider Practice Location Address
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Address Line | 70 E 91ST ST STE 101
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City | INDIANAPOLIS
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State | IN
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Zip | 46240-1550
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Country | US
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Telephone | 312-972-8307
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Fax |
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Provider Business Mailing Address
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Address Line | 14251 LANGHAM DR
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City | CARMEL
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State | IN
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Zip | 46074-4401
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Country | US
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Telephone | 312-972-8307
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TORI LYNN MATTHEWS
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Credential | MA
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Telephone | 817-915-9965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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