Provider Demographics
NPI:1194316596
Name:MEDICAL CENTER FOR JOINT RESTORATION AND REGENERATIVE MEDICINE, LLC
Entity type:Organization
Organization Name:MEDICAL CENTER FOR JOINT RESTORATION AND REGENERATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:ESTHER
Authorized Official - Last Name:GIRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-822-1516
Mailing Address - Street 1:3900 S WALNUT ST STE A
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7331
Mailing Address - Country:US
Mailing Address - Phone:812-822-1516
Mailing Address - Fax:
Practice Address - Street 1:3900 S WALNUT ST STE A
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7331
Practice Address - Country:US
Practice Address - Phone:812-822-1516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty