Healthcare Provider Details

I. General information

NPI: 1316418320
Provider Name (Legal Business Name): RENEE CLONTZ RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 E PERSHING BLVD
CHEYENNE WY
82001-5356
US

IV. Provider business mailing address

2512 STARLIGHT CT
CHEYENNE WY
82009-9746
US

V. Phone/Fax

Practice location:
  • Phone: 503-991-8070
  • Fax:
Mailing address:
  • Phone: 503-991-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: