Provider Demographics
NPI:1689641433
Name:LARRY E. RENEKER, D.O., PA
Entity Type:Organization
Organization Name:LARRY E. RENEKER, D.O., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:RENEKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-586-0035
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-0037
Mailing Address - Country:US
Mailing Address - Phone:386-586-0035
Mailing Address - Fax:386-586-0490
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:STE: 2804
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5981
Practice Address - Country:US
Practice Address - Phone:386-586-0035
Practice Address - Fax:386-586-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG13801Medicare UPIN
FL57217AMedicare PIN