Healthcare Provider Details

I. General information

NPI: 1366618118
Provider Name (Legal Business Name): TIFFANY RENAUD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 WILLISTON RD SUITE 3
SOUTH BURLINGTON VT
05403-6082
US

IV. Provider business mailing address

3000 WILLISTON RD SUITE 3
SOUTH BURLINGTON VT
05403-6082
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-6092
  • Fax: 802-863-9565
Mailing address:
  • Phone: 802-658-6092
  • Fax: 802-863-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0060000905
License Number StateVT

VIII. Authorized Official

Name: TIFFANY RENAUD
Title or Position: PRESIDENT
Credential: D.C.
Phone: 802-658-6092