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General NPI Number Information
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NPI Number | 1639933286
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Entity Type | Organization
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Legal Business Name | RENEW AESTHETICS AND REGENERATIVE MEDICINE
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Dates
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Enumeration Date | 02/13/2024
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Last Update Date | 02/13/2024
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Provider Practice Location Address
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Address Line | 6302 112TH ST E STE 300
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City | PUYALLUP
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State | WA
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Zip | 98373-4315
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Country | US
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Telephone | 253-651-9263
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Fax |
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Provider Business Mailing Address
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Address Line | 16616 139TH AVE E
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City | PUYALLUP
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State | WA
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Zip | 98374-8830
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Country | US
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Telephone | 619-669-8847
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER, CLINIC OWN
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Name | MR. MICHAEL LORAH
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Credential |
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Telephone | 619-669-8847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202D00000X
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Taxonomy Name | Integrative Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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