Provider Demographics
NPI:1962973156
Name:REGENERATIVE THERAPY OF GEORGIA
Entity type:Organization
Organization Name:REGENERATIVE THERAPY OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAKENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULBRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-906-1316
Mailing Address - Street 1:5132 PANOLA MILL DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2351
Mailing Address - Country:US
Mailing Address - Phone:770-906-1316
Mailing Address - Fax:
Practice Address - Street 1:5040 SNAPFINGER WOODS DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30035
Practice Address - Country:US
Practice Address - Phone:770-380-6560
Practice Address - Fax:770-502-6745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service