Healthcare Provider Details

I. General information

NPI: 1972205003
Provider Name (Legal Business Name): RENEW PHYSICAL THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 GENTIAN RD
ST AUGUSTINE FL
32086-6426
US

IV. Provider business mailing address

424 GENTIAN RD
ST AUGUSTINE FL
32086-6426
US

V. Phone/Fax

Practice location:
  • Phone: 904-599-5459
  • Fax:
Mailing address:
  • Phone: 904-599-5459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW RIEDER
Title or Position: OWNER
Credential: DPT
Phone: 904-599-5459