Healthcare Provider Details

I. General information

NPI: 1649396631
Provider Name (Legal Business Name): GREGORY WAYNE RENEAU DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 NW GARDEN VALLEY BLVD SUITE #300
ROSEBURG OR
97470-1955
US

IV. Provider business mailing address

1632 NW HUGHWOOD CT
ROSEBURG OR
97471-8881
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-9199
  • Fax: 541-672-4326
Mailing address:
  • Phone: 541-677-9199
  • Fax: 541-672-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number273422
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: