Provider Demographics
NPI:1407681687
Name:WELLSPRING REGENERATIVE HEALTH, LLC
Entity type:Organization
Organization Name:WELLSPRING REGENERATIVE HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:816-651-7813
Mailing Address - Street 1:12120 STATE LINE RD # 125
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-1254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13160 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-1708
Practice Address - Country:US
Practice Address - Phone:816-651-7813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407567068Medicaid
MO1851823694Medicaid