MEDICARE: RENOM MEDICAL PLLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1528723079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENOM MEDICAL PLLC

Provider Business Mailing Address
First Line	:	6850 HIGHWAY 6 S STE 121B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-3302
Country	:	US
Telephone Number	:	832-557-9060
Fax Number	:

Provider Business Practice Location Address
First Line	:	6850 HIGHWAY 6 S STE 121B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-3302
Country	:	US
Telephone Number	:	832-557-9060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WILL IBANGA
Credential	:	MD
Telephone Number	:	832-557-9060

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/01/2021

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