Provider Demographics
NPI:1639410434
Name:RENEW PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:RENEW PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:920-833-2284
Mailing Address - Street 1:2701 LARSEN RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4863
Mailing Address - Country:US
Mailing Address - Phone:920-883-2284
Mailing Address - Fax:
Practice Address - Street 1:2701 LARSEN RD
Practice Address - Street 2:SUITE 111
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4863
Practice Address - Country:US
Practice Address - Phone:920-883-2284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy