MEDICARE: RENOVARE CLINIC OF NATURAL MEDICINE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	7243	AZ
2	171100000X	Acupuncturist	7243	AZ
3	111NI0900X	Internist Chiropractor	7243	AZ

General Provider Information

NPI Number	:	1902974678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENOVARE CLINIC OF NATURAL MEDICINE PA

Provider Business Mailing Address
First Line	:	18301 NORTH 79TH AVE
Second Line	:	SUITE G190
City	:	GLENDALE
State	:	AZ
Zip	:	85308
Country	:	US
Telephone Number	:	623-776-0206
Fax Number	:	623-776-0282

Provider Business Practice Location Address
First Line	:	18301 NORTH 79TH AVE
Second Line	:	SUITE G190
City	:	GLENDALE
State	:	AZ
Zip	:	85308
Country	:	US
Telephone Number	:	623-776-0206
Fax Number	:	623-776-0282

Authorized Official
Title or Position	:	CEO
Name	:	DR. TIMOTHY CHARLES GERHART
Credential	:	DC
Telephone Number	:	623-776-0206

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	04/08/2008

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