1689641433 NPI number — LARRY E. RENEKER, D.O., PA

Table of content: (NPI 1689641433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689641433 NPI number — LARRY E. RENEKER, D.O., PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY E. RENEKER, D.O., PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689641433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGLER BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32136-0037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-586-0035
Provider Business Mailing Address Fax Number:
386-586-0490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
61 MEMORIAL MEDICAL PKWY
Provider Second Line Business Practice Location Address:
STE: 2804
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-5981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-586-0035
Provider Business Practice Location Address Fax Number:
386-586-0490
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RENEKER
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
386-586-0035

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS7082 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com