Basic Information
| Provider Information | |||||||||
| NPI: | 1285200584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENERATION PSYCHIATRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2512 ARTESIA BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902783274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4242772899 | ||||||||
| FaxNumber: | 4242772899 | ||||||||
| Practice Location | |||||||||
| Address1: | 2512 ARTESIA BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902783274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4242772899 | ||||||||
| FaxNumber: | 4242772899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2021 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | POBLETE | ||||||||
| AuthorizedOfficialFirstName: | JOBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4242772899 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.