Provider Demographics
NPI:1164291688
Name:RENOVA PT LLC
Entity Type:Organization
Organization Name:RENOVA PT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:
Authorized Official - Last Name:DE BRUN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:404-797-5058
Mailing Address - Street 1:1113 TUSCULUM BLVD # 104
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 CALICO RD
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:TN
Practice Address - Zip Code:37616-6631
Practice Address - Country:US
Practice Address - Phone:423-788-5106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty