Regen Lab USA - PRIA Enrollment

Provider Enrollment - RegenLab USA

User Contact Name

First

Last

User Contact Email *

User Contact Phone *

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address *

Practice Address

City

State/Province

Zip/Postal

Practice Tax ID *

Practice NPI *

Physician Name *

Physician Tax ID *

Physician NPI *

Physician PTAN *

Facility Name *

Facility Address *

Facility Address

City

State/Province

Zip/Postal

Facility Phone *

Facility Tax ID *

Facility NPI *

Regen Lab USA Sales Representative Name *

Date: Onboarding Call Availability (Option 1)

Date: Onboarding Call Availability (Option 2)

Time EST (Option 1)

Time EST (Option 2)

PROGRAM SUPPORT:

MONDAY–FRIDAY 8:30AM–5:00PM EST
PHONE: 860-374-2712 FAX: 860-734-4795
EMAIL: REGENLABUSA@PRIAHEALTHCARE.COM