Healthcare Provider Details

I. General information

NPI: 1730144163
Provider Name (Legal Business Name): RENAISSANCE PLASTIC SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 NOKOMIS AVE S
VENICE FL
34285-2452
US

IV. Provider business mailing address

321 NOKOMIS AVE S
VENICE FL
34285-2452
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-7727
  • Fax: 941-488-7818
Mailing address:
  • Phone: 941-488-7727
  • Fax: 941-488-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES L. RODRIGUEZ
Title or Position: OWNER
Credential: M.D.
Phone: 941-488-7727