Healthcare Provider Details

I. General information

NPI: 1063704427
Provider Name (Legal Business Name): RENEWAL CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 NE BURNSIDE RD
GRESHAM OR
97030-5713
US

IV. Provider business mailing address

1240 NE BURNSIDE RD
GRESHAM OR
97030-5713
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-9300
  • Fax: 503-667-4975
Mailing address:
  • Phone: 503-667-9300
  • Fax: 503-667-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3026
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number0932
License Number StateOR

VIII. Authorized Official

Name: JONATHAN HANSEL
Title or Position: OWNER
Credential: ND, DC
Phone: 503-667-9300