=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952021891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL EVIDENCE REGEN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2022
-----------------------------------------------------
Last Update Date | 08/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7035 BERACASA WAY STE 103
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-674-1217
-----------------------------------------------------
Fax | 561-287-6556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7035 BERACASA WAY STE 103
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-674-1217
-----------------------------------------------------
Fax | 561-287-6556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | DR. DAVID LIPMAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 561-674-1217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202D00000X
-----------------------------------------------------
Taxonomy Name | Integrative Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------