MEDICARE: BODY RENEWAL LASER CENTERS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AP2026	FL

General Provider Information

NPI Number	:	1184954778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY RENEWAL LASER CENTERS LLC

Provider Business Mailing Address
First Line	:	6815 14TH ST W STE 208
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34207-5810
Country	:	US
Telephone Number	:	941-751-2345
Fax Number	:	941-751-6336

Provider Business Practice Location Address
First Line	:	6815 14TH ST W STE 208
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34207-5810
Country	:	US
Telephone Number	:	941-751-2345
Fax Number	:	941-751-6336

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NANCIE JEAN BRENES
Credential	:	DOM, AP
Telephone Number	:	941-751-2345

Provider Enumeration Date	:	01/05/2010
Last Update Date	:	01/05/2010

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