MEDICARE: RENEWED WELLNESS

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	111N00000X	Chiropractor	CH-10445	FL
2	111N00000X	Chiropractor	CH-9460	FL

General Provider Information

NPI Number	:	1548603327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEWED WELLNESS

Provider Business Mailing Address
First Line	:	5201 HOLLYWOOD BLVD
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6422
Country	:	US
Telephone Number	:	954-964-6000
Fax Number	:	954-964-3444

Provider Business Practice Location Address
First Line	:	5201 HOLLYWOOD BLVD
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-6422
Country	:	US
Telephone Number	:	954-964-6000
Fax Number	:	954-964-3444

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	CLYDELL L. DEWBERRY
Credential	:	D.C.
Telephone Number	:	405-639-7140

Provider Enumeration Date	:	04/11/2013
Last Update Date	:	04/11/2013

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Directions to “RENEWED WELLNESS ” Practice Location

Language	Start Address	Practice Location

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