Provider Demographics
NPI:1265839187
Name:RENZETTI, TARA C
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:RENZETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31764 CASINO DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4571
Mailing Address - Country:US
Mailing Address - Phone:951-471-4645
Mailing Address - Fax:
Practice Address - Street 1:31764 CASINO DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4571
Practice Address - Country:US
Practice Address - Phone:951-471-4645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator