Healthcare Provider Details

I. General information

NPI: 1265993190
Provider Name (Legal Business Name): RENNETTE NICOLE ZAVALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WOOD ST
SPARTANBURG SC
29303-3040
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-1576
  • Fax: 864-560-1590
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number92873
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: