Provider Demographics
NPI:1366831554
Name:REGENESIS LLC
Entity type:Organization
Organization Name:REGENESIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:8500-889-0711
Mailing Address - Street 1:4960 HWY 90 SUITE 115
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571
Mailing Address - Country:US
Mailing Address - Phone:850-889-0711
Mailing Address - Fax:850-807-5059
Practice Address - Street 1:4960 HIGHWAY 90 STE 115
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1413
Practice Address - Country:US
Practice Address - Phone:850-889-0711
Practice Address - Fax:850-807-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108469363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty