Healthcare Provider Details

I. General information

NPI: 1932550480
Provider Name (Legal Business Name): RENEW AND RESTORE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 ALTON RD STE 710
MIAMI BEACH FL
33140-4557
US

IV. Provider business mailing address

4308 ALTON RD STE 710
MIAMI BEACH FL
33140-4557
US

V. Phone/Fax

Practice location:
  • Phone: 305-695-7777
  • Fax: 305-695-7707
Mailing address:
  • Phone: 305-695-7777
  • Fax: 305-695-7707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS12833
License Number StateFL

VIII. Authorized Official

Name: JEFF BAKER
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 305-695-7777