Healthcare Provider Details

I. General information

NPI: 1326224189
Provider Name (Legal Business Name): ALRENWALD-THERANOVA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2359 W 13TH LN
YUMA AZ
85364-4376
US

IV. Provider business mailing address

2359 W 13TH LN
YUMA AZ
85364-4376
US

V. Phone/Fax

Practice location:
  • Phone: 928-376-6650
  • Fax: 928-343-7990
Mailing address:
  • Phone: 928-376-6650
  • Fax: 928-343-7990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND LANCE WALDROP
Title or Position: BUSINESS MANAGER
Credential:
Phone: 928-376-6650