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General NPI Number Information
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NPI Number | 1689641433
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Entity Type | Organization
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Legal Business Name | LARRY E. RENEKER, D.O., PA
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Dates
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Enumeration Date | 03/01/2006
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 61 MEMORIAL MEDICAL PKWY STE: 2804
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City | PALM COAST
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State | FL
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Zip | 32164-5981
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Country | US
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Telephone | 386-586-0035
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Fax | 386-586-0490
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Provider Business Mailing Address
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Address Line | PO BOX 37
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City | FLAGLER BEACH
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State | FL
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Zip | 32136-0037
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Country | US
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Telephone | 386-586-0035
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Fax | 386-586-0490
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. LARRY EARL RENEKER
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Credential | D.O.
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Telephone | 386-586-0035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS7082
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License Number State | FL
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