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Regenerize Psychiatry PLLC

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Company Details

Name: Regenerize Psychiatry PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 21 Jun 2024 (a year ago)
Financial Date End: 30 Jun 2026
Entity Number: 5786635
Place of Formation: IDAHO
File Number: 942805
ZIP code: 83864
County: Bonner County
Principal Address: 605 S OLIVE AVE SANDPOINT, ID 83864
Mailing Address: 605 S OLIVE AVE SANDPOINT, ID 83864-1154

Manager

Name Role Address Appointed On
Regenerize PLLC Manager 605 S OLIVE AVE, SANDPOINT, ID 83864 2025-05-05

Agent

Name Role Address
Regenerize PLLC Agent 605 S OLIVE AVE, SANDPOINT, ID 83864

National Provider Identifier

NPI Number:
1043054075
Certification Date:
2024-10-27

Authorized Person:

Name:
RADLEY PETERSON
Role:
OWNER
Phone:

Taxonomy:

Selected Taxonomy:
261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center)
Is Primary:
Yes

Contacts:

Filing

Filing Name Filing Number Filing date
Annual Report 0006235264 2025-05-05
Initial Filing 0005786635 2024-06-21

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Date of last update: 23 May 2025

Sources: Idaho Secretary of State