Provider Demographics
NPI:1154714913
Name:REGENESYS
Entity type:Organization
Organization Name:REGENESYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GAEDE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, CMHC
Authorized Official - Phone:801-410-1671
Mailing Address - Street 1:1429 S 550 E
Mailing Address - Street 2:#4
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-7793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1429 S 550 E
Practice Address - Street 2:#4
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7793
Practice Address - Country:US
Practice Address - Phone:801-410-1671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT268792-6004251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health