Provider Demographics
NPI:1588256069
Name:THEA CENTER FOR REGENERATIVE MEDICINE
Entity type:Organization
Organization Name:THEA CENTER FOR REGENERATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-592-7504
Mailing Address - Street 1:9568 TOPANGA CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-4011
Mailing Address - Country:US
Mailing Address - Phone:818-356-8232
Mailing Address - Fax:
Practice Address - Street 1:9568 TOPANGA CANYON BLVD
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-4011
Practice Address - Country:US
Practice Address - Phone:818-356-8232
Practice Address - Fax:818-483-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-06
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty