Provider Demographics
NPI:1619634789
Name:RENEGADE WAREHOUSE
Entity Type:Organization
Organization Name:RENEGADE WAREHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MUNCY
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:937-694-6226
Mailing Address - Street 1:1061 DECKER DR
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6415
Mailing Address - Country:US
Mailing Address - Phone:937-694-6226
Mailing Address - Fax:
Practice Address - Street 1:10841 WOOD RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-694-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy