=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194990739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENAISSANCE ORTHOPAEDIC CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2008
-----------------------------------------------------
Last Update Date | 04/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 CLOYD BLVD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35630-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-768-9928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 CLOYD BLVD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35630-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-768-9928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | LLOYD JOHNSON III
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 256-768-9928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD25810
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------