Provider Demographics
NPI:1619976743
Name:RENICK, STEPHEN JR (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:RENICK
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2658 MAGUIRE RD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4752
Mailing Address - Country:US
Mailing Address - Phone:407-877-2400
Mailing Address - Fax:407-877-0958
Practice Address - Street 1:2658 MAGUIRE RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4752
Practice Address - Country:US
Practice Address - Phone:407-877-2400
Practice Address - Fax:407-877-0958
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2538111NN1001X
FLCH9701111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX14791Medicare PIN