Provider Demographics
NPI:1053937946
Name:SOUTHWEST REGENERATIVE MEDICINE LLC
Entity type:Organization
Organization Name:SOUTHWEST REGENERATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC-APC
Authorized Official - Phone:575-532-7050
Mailing Address - Street 1:755 S TELSHOR BLVD # R101
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4688
Mailing Address - Country:US
Mailing Address - Phone:575-532-7050
Mailing Address - Fax:
Practice Address - Street 1:755 S TELSHOR BLVD # R101
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4688
Practice Address - Country:US
Practice Address - Phone:575-532-7050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies