=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396205126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS LAMAR RENCHER JR. ATC, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2019
-----------------------------------------------------
Last Update Date | 01/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4045 E BELL RD STE 150
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-2239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-744-6331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15757 N 90TH PL APT 1005
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-2003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-744-6331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | ATR-009354
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | LPT-034574
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------