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General NPI Number Information
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NPI Number | 1164739025
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Entity Type | Organization
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Legal Business Name | RENEW MEDICAL SPA LLC
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Dates
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Enumeration Date | 09/13/2010
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 3939 TEXAS BLVD
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City | TEXARKANA
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State | TX
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Zip | 75503-3207
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Country | US
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Telephone | 903-255-6398
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Fax | 903-794-6304
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Provider Business Mailing Address
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Address Line | 3939 TEXAS BLVD
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City | TEXARKANA
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State | TX
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Zip | 75503-3207
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Country | US
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Telephone | 903-255-6398
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Fax | 903-794-6304
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Authorized Official
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Title or Position | OWNER
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Name | MRS. THERESA M FONTENOT
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Credential | PA-C
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Telephone | 903-255-6398
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | PA00892
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | PA-190
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License Number State | AR
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