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General NPI Number Information
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NPI Number | 1164291688
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Entity Type | Organization
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Legal Business Name | RENOVA PT LLC
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Dates
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Enumeration Date | 12/26/2023
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Last Update Date | 01/06/2025
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Provider Practice Location Address
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Address Line | 5515 WARRENSBURG RD
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City | GREENEVILLE
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State | TN
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Zip | 37743-3282
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Country | US
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Telephone | 423-788-5106
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Fax |
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Provider Business Mailing Address
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Address Line | 1113 TUSCULUM BLVD # 104
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City | GREENEVILLE
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State | TN
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Zip | 37745-4038
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MILTON DE BRUN
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Credential | D.P.T
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Telephone | 404-797-5058
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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 |
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License Number State |
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