Healthcare Provider Details

I. General information

NPI: 1619447158
Provider Name (Legal Business Name): BEAU RENAUD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 ANDRIEUX ST
SONOMA CA
95476-6811
US

IV. Provider business mailing address

880 MADIGAN AVE
CONCORD CA
94518-2147
US

V. Phone/Fax

Practice location:
  • Phone: 707-935-5000
  • Fax:
Mailing address:
  • Phone: 480-272-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: