Healthcare Provider Details

I. General information

NPI: 1457510604
Provider Name (Legal Business Name): MATTHEW EDWARD RENNER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MATT RENNER PT

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6744 CLAYTON RD SUITE 220
SAINT LOUIS MO
63117-1637
US

IV. Provider business mailing address

6744 CLAYTON RD SUITE 220
SAINT LOUIS MO
63117-1637
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-1978
  • Fax: 314-647-1350
Mailing address:
  • Phone: 314-644-1978
  • Fax: 314-647-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007008752
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: