Healthcare Provider Details

I. General information

NPI: 1952093031
Provider Name (Legal Business Name): RENEW PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

IV. Provider business mailing address

PO BOX 8244
ROSWELL NM
88202-8244
US

V. Phone/Fax

Practice location:
  • Phone: 575-214-2355
  • Fax: 575-286-0284
Mailing address:
  • Phone: 575-214-2355
  • Fax: 575-286-0284

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: KIM PARKER-GUERRERO
Title or Position: OWNER/PROVIDER
Credential: DPT
Phone: 575-214-2355