MEDICARE: RENEW TOXICOLOGY

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1760874077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW TOXICOLOGY

Provider Business Mailing Address
First Line	:	2310 W INTERSTATE 20 STE 202
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-1678
Country	:	US
Telephone Number	:	817-717-7605
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 S HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1967
Country	:	US
Telephone Number	:	817-717-7605
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	ALISON REEVES
Credential	:
Telephone Number	:	817-360-4829

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	06/20/2016

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Directions to “RENEW TOXICOLOGY ” Practice Location

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