Basic Information
| Provider Information | |||||||||
| NPI: | 1215473103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REGEN | ||||||||
| FirstName: | ETHAN | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3907 HENRICKS HILL DR | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371678368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159572403 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2021 CHURCH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153241600 | ||||||||
| FaxNumber: | 6152842003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2017 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 1873 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.