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General NPI Number Information
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NPI Number | 1013436641
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Entity Type | Organization
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Legal Business Name | RENEW MANUAL PHYSICAL THERAPY PLLC
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Dates
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Enumeration Date | 09/14/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 7444 W SAXTON DR # K101
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City | BOISE
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State | ID
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Zip | 83714-1316
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Country | US
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Telephone | 602-515-6659
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Fax |
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Provider Business Mailing Address
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Address Line | 7444 W SAXTON DR # K101
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City | BOISE
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State | ID
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Zip | 83714-1316
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Country | US
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Telephone | 602-515-6659
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | DR. BREANN FAYE SUDDOCK FOX
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Credential | PT, DPT, PRPC
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Telephone | 602-515-6659
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-5245
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License Number State | ID
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