MEDICARE: LOUISIANA REGENERATIVE MEDICINE CENTER

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	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1790301596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA REGENERATIVE MEDICINE CENTER

Provider Business Mailing Address
First Line	:	9456 JEFFERSON HWY
Second Line	:	ST A
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-2883
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9456 JEFFERSON HWY ST A
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809
Country	:	US
Telephone Number	:	225-716-9100
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ELIZABETH R CONSTANT
Credential	:
Telephone Number	:	985-414-4530

Provider Enumeration Date	:	06/18/2020
Last Update Date	:	06/18/2020

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