Healthcare Provider Details

I. General information

NPI: 1720385867
Provider Name (Legal Business Name): RENATA STURDIVANT B.S., RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 RIVERSIDE PARK DR
SAN ANTONIO TX
78249-4324
US

IV. Provider business mailing address

3516 W MARY KNOLL CT
PEORIA IL
61615-3727
US

V. Phone/Fax

Practice location:
  • Phone: 309-258-1194
  • Fax:
Mailing address:
  • Phone: 309-258-1194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: