MEDICARE: RENAISSANCE NEURODIAGNOSTICS PA

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	207X00000X	Orthopaedic Surgery Physician
2	207XS0117X	Orthopaedic Surgery of the Spine Physician	N7365	TX

General Provider Information

NPI Number	:	1629355946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE NEURODIAGNOSTICS PA

Provider Business Mailing Address
First Line	:	7712 SAN JACINTO PLACE
Second Line	:	SUITE 200
City	:	PLANO
State	:	TX
Zip	:	75024-3212
Country	:	US
Telephone Number	:	972-707-0005
Fax Number	:	888-992-6199

Provider Business Practice Location Address
First Line	:	7712 SAN JACINTO PLACE
Second Line	:	SUITE 200
City	:	PLANO
State	:	TX
Zip	:	75024-3212
Country	:	US
Telephone Number	:	972-707-0005
Fax Number	:	888-992-6199

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. MARK CHARLIE VALENTE
Credential	:	D.O
Telephone Number	:	214-384-1642

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	08/29/2014

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