MEDICARE: RENEW PHYSICAL THERAPY AND WELLNESS CENTER, LLC

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	261QP2000X	Physical Therapy Clinic/Center	20141	MD

General Provider Information

NPI Number	:	1942438379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW PHYSICAL THERAPY AND WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	938 E SWAN CREEK RD
Second Line	:	SUITE 269
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-5250
Country	:	US
Telephone Number	:	301-613-2011
Fax Number	:

Provider Business Practice Location Address
First Line	:	938 E SWAN CREEK RD
Second Line	:	SUITE 269
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-5250
Country	:	US
Telephone Number	:	301-613-2011
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. TAMARA EVETTE JOHNSON
Credential	:	MSPT
Telephone Number	:	301-613-2011

Provider Enumeration Date	:	06/24/2009
Last Update Date	:	06/24/2009

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