1972092989 NPI number — RENEW PHYSICAL THERAPY AND WELLNESS, LLC

Table of content: (NPI 1972092989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972092989 NPI number — RENEW PHYSICAL THERAPY AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENEW PHYSICAL THERAPY AND WELLNESS, LLC
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:
6
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:
1972092989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 5TH AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUNCTION CITY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54443-9411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-228-2755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N2919 COUNTY ROAD QQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUPACA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-228-2755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-228-2755

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com