MEDICARE: RENETTA HENAULT P.T.

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	225100000X	Physical Therapist	21626	CA

General Provider Information

NPI Number	:	1336683887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENETTA HENAULT P.T.

Provider Business Mailing Address
First Line	:	6568 KORHUMMEL WAY
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95119-1919
Country	:	US
Telephone Number	:	408-644-6311
Fax Number	:

Provider Business Practice Location Address
First Line	:	6568 KORHUMMEL WAY
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95119-1919
Country	:	US
Telephone Number	:	408-644-6311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2016
Last Update Date	:	12/16/2016

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