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General NPI Number Information
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NPI Number | 1962804112
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Entity Type | Organization
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Legal Business Name | RENEW YOU THERAPIES & BEAUTY LLC
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Dates
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Enumeration Date | 09/18/2014
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Last Update Date | 09/18/2014
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Provider Practice Location Address
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Address Line | 1111 S ORCHARD ST STE 160
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City | BOISE
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State | ID
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Zip | 83705-1977
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Country | US
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Telephone | 208-546-9355
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Fax |
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Provider Business Mailing Address
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Address Line | 1111 S ORCHARD ST STE 160
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City | BOISE
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State | ID
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Zip | 83705-1977
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Country | US
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Telephone | 208-546-9355
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TESLA HEIDI GILLESPIE
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Credential | LMT
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Telephone | 208-546-9355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MASG-303
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License Number State | ID
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