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General NPI Number Information
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NPI Number | 1770100893
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Entity Type | Organization
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Legal Business Name | RENEGADE MOVEMENT AND PERFORMANCE, LLC
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Dates
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Enumeration Date | 07/06/2020
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Last Update Date | 06/15/2022
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Provider Practice Location Address
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Address Line | 10 COMMERCE PARK N STE 7B
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City | BEDFORD
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State | NH
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Zip | 03110-6907
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Country | US
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Telephone | 603-267-0432
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Fax |
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Provider Business Mailing Address
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Address Line | 195 MCGREGOR ST APT 414
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City | MANCHESTER
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State | NH
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Zip | 03102-3777
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Country | US
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Telephone | 315-573-0705
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST, CO-OWNER
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Name | ALEXIS BRUNELLE
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Credential | PT, DPT
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Telephone | 315-573-0705
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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