Provider Demographics
NPI:1043734304
Name:RENDER, CAROL MARIE (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MARIE
Last Name:RENDER
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 PILOT HOUSE DR STE 100A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4411
Mailing Address - Country:US
Mailing Address - Phone:757-592-9102
Mailing Address - Fax:
Practice Address - Street 1:780 PILOT HOUSE DR STE 100A
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4411
Practice Address - Country:US
Practice Address - Phone:757-592-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA001900966225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist