Provider Demographics
NPI:1659107449
Name:REGENERATE PHYSICAL THERAPY & PERFORMANCE LLC
Entity type:Organization
Organization Name:REGENERATE PHYSICAL THERAPY & PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:JARDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:269-235-9816
Mailing Address - Street 1:515 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2911
Mailing Address - Country:US
Mailing Address - Phone:269-449-7455
Mailing Address - Fax:
Practice Address - Street 1:8750 W CAMPUS CIRCLE DR ROOM 167
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49104-0001
Practice Address - Country:US
Practice Address - Phone:269-235-9816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty