Provider Demographics
NPI:1619163409
Name:RENEWAL DERMATOLOGY AND LASER, APMC
Entity Type:Organization
Organization Name:RENEWAL DERMATOLOGY AND LASER, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KAMENETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-550-0440
Mailing Address - Street 1:PO BOX 34120
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-4120
Mailing Address - Country:US
Mailing Address - Phone:775-747-5050
Mailing Address - Fax:775-329-8596
Practice Address - Street 1:10870 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-2054
Practice Address - Country:US
Practice Address - Phone:530-550-0440
Practice Address - Fax:530-582-8853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75315207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF74283Medicare UPIN
CAZZZ07475ZMedicare PIN
CA00G75315Medicare PIN