MEDICARE: REGENESIS MODERN HEALTH PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1396318663
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENESIS MODERN HEALTH PLLC

Provider Business Mailing Address
First Line	:	5955 ALPHA RD # 1089
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75240-1121
Country	:	US
Telephone Number	:	972-200-7022
Fax Number	:

Provider Business Practice Location Address
First Line	:	5955 ALPHA RD # 1089
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75240-1121
Country	:	US
Telephone Number	:	972-200-7022
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALISON HARRIS
Credential	:	NP
Telephone Number	:	972-782-4768

Provider Enumeration Date	:	07/23/2021
Last Update Date	:	08/18/2021

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