Provider Demographics
NPI:1255508453
Name:RENEW PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:RENEW PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGIELLO
Authorized Official - Suffix:I
Authorized Official - Credentials:PT
Authorized Official - Phone:415-381-8707
Mailing Address - Street 1:1427 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3118
Mailing Address - Country:US
Mailing Address - Phone:415-895-6995
Mailing Address - Fax:415-707-6776
Practice Address - Street 1:1427 GRANT AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945
Practice Address - Country:US
Practice Address - Phone:415-895-1705
Practice Address - Fax:415-707-6776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23976261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy