Provider Demographics
NPI:1164739025
Name:RENEW MEDICAL SPA LLC
Entity Type:Organization
Organization Name:RENEW MEDICAL SPA LLC
Other - Org Name:RENEW MEDICAL SPA AND NUTRITIONAL WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:903-255-6398
Mailing Address - Street 1:3939 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3207
Mailing Address - Country:US
Mailing Address - Phone:903-255-6398
Mailing Address - Fax:903-794-6304
Practice Address - Street 1:3939 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3207
Practice Address - Country:US
Practice Address - Phone:903-255-6398
Practice Address - Fax:903-794-6304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00892261QM2500X
ARPA-190261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4995690001OtherCIGNA GOVERMENT SERVICES
R64719Medicare UPIN
TX4995690001OtherCIGNA GOVERMENT SERVICES