Healthcare Provider Details

I. General information

NPI: 1578717781
Provider Name (Legal Business Name): PAUL R RENNIE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 AMERICAN PACIFIC DR
HENDERSON NV
89014-8800
US

IV. Provider business mailing address

1801 W OLYMPIC BLVD # 2265
PASADENA CA
91199-0001
US

V. Phone/Fax

Practice location:
  • Phone: 702-777-4809
  • Fax: 702-777-4822
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number579
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number579
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: