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General NPI Number Information
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NPI Number | 1639801491
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Entity Type | Organization
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Legal Business Name | RENACER MEDICAL GROUP LLC
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Dates
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Enumeration Date | 06/29/2022
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Last Update Date | 10/02/2025
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Provider Practice Location Address
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Address Line | 1647 SW 27TH AVE
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City | MIAMI
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State | FL
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Zip | 33145-2044
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Country | US
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Telephone | 305-456-6205
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Fax | 305-456-6207
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Provider Business Mailing Address
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Address Line | 1647 SW 27TH AVE
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City | MIAMI
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State | FL
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Zip | 33145-2044
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Country | US
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Telephone | 305-456-6205
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Fax | 305-456-6207
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Authorized Official
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Title or Position | AMBR
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Name | MARIANELA DE LA PORTILLA
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Credential | MD
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Telephone | 305-456-6205
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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