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General NPI Number Information
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NPI Number | 1932550480
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Entity Type | Organization
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Legal Business Name | RENEW AND RESTORE MEDICAL
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Dates
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Enumeration Date | 06/27/2016
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Last Update Date | 06/27/2016
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Provider Practice Location Address
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Address Line | 4308 ALTON RD STE 710
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City | MIAMI BEACH
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State | FL
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Zip | 33140-4557
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Country | US
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Telephone | 305-695-7777
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Fax | 305-695-7707
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Provider Business Mailing Address
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Address Line | 4308 ALTON RD STE 710
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City | MIAMI BEACH
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State | FL
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Zip | 33140-4557
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Country | US
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Telephone | 305-695-7777
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Fax | 305-695-7707
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JEFF BAKER
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Credential | DO
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Telephone | 305-695-7777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | OS12833
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License Number State | FL
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