Basic Information
| Provider Information | |||||||||
| NPI: | 1457854812 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INSTITUTE FOR PHYSICAL AND REGENERATIVE MEDICINE PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INSTITUTE FOR PHYSICAL AND REGENERATIVE MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26603 INTERSTATE 45 | ||||||||
| Address2: | |||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773801907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813676900 | ||||||||
| FaxNumber: | 2813676255 | ||||||||
| Practice Location | |||||||||
| Address1: | 26603 INTERSTATE 45 | ||||||||
| Address2: | |||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773801907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813676900 | ||||||||
| FaxNumber: | 2813676255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2018 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DURRETT | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2813676900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2976 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.