Healthcare Provider Details

I. General information

NPI: 1093329948
Provider Name (Legal Business Name): RYAN PATRICK RENKIEWICZ ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 W 4800 S
ROY UT
84067-1844
US

IV. Provider business mailing address

5890 S 4550 W
HOOPER UT
84315-6771
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-3600
  • Fax:
Mailing address:
  • Phone: 231-920-0924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8081236-4810
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: