Healthcare Provider Details

I. General information

NPI: 1205305430
Provider Name (Legal Business Name): RENUVA XTREMITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 KIRBY PKWY STE 5
MEMPHIS TN
38119
US

IV. Provider business mailing address

2900 KIRBY PKWY STE 5
MEMPHIS TN
38119
US

V. Phone/Fax

Practice location:
  • Phone: 901-309-8898
  • Fax: 901-309-5908
Mailing address:
  • Phone: 901-309-8898
  • Fax: 901-309-5908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHAN LUCAS JR.
Title or Position: PODIATRIST
Credential: DPM
Phone: 901-309-8898