Provider Demographics
NPI:1407129125
Name:RENU MEDISPA
Entity Type:Organization
Organization Name:RENU MEDISPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAWNI
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-939-4456
Mailing Address - Street 1:951 E PLAZA DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6566
Mailing Address - Country:US
Mailing Address - Phone:208-939-4456
Mailing Address - Fax:208-287-2200
Practice Address - Street 1:951 E PLAZA DR
Practice Address - Street 2:SUITE 150
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6566
Practice Address - Country:US
Practice Address - Phone:208-939-4456
Practice Address - Fax:208-287-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP784A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center