=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649988403
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENOVARE PHYSICAL THERAPY AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2022
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 E VANCE ST STE A
-----------------------------------------------------
City | FUQUAY VARINA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27526-2264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-344-7506
-----------------------------------------------------
Fax | 984-201-0215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5212 GABLE RIDGE LN
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27540-9306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-344-7506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | COLLEEN GREENE
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 984-344-7506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------