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General NPI Number Information
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NPI Number | 1184097388
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Entity Type | Organization
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Legal Business Name | RENEW PHYSICAL THERAPY INC
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Dates
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Enumeration Date | 11/10/2015
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Last Update Date | 01/14/2016
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Provider Practice Location Address
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Address Line | 325 5TH AVE SUITE 103
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City | INDIALANTIC
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State | FL
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Zip | 32903-4273
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Country | US
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Telephone | 321-537-2657
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 33099
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City | INDIALANTIC
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State | FL
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Zip | 32903-0099
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Country | US
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Telephone | 321-956-0485
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Fax |
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Authorized Official
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Title or Position | AGENT
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Name | TERRI JOHNSON
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Credential |
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Telephone | 321-537-9311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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