Provider Demographics
NPI: | 1710246541 |
---|---|
Name: | RENEW WELLNESS SERVICES PLLC |
Entity Type: | Organization |
Organization Name: | RENEW WELLNESS SERVICES PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PROVIDER |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | THERESA |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | FONTENOT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PA-C |
Authorized Official - Phone: | 903-255-6398 |
Mailing Address - Street 1: | 3939 TEXAS BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | TEXARKANA |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75503-3207 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-255-6398 |
Mailing Address - Fax: | 903-794-6305 |
Practice Address - Street 1: | 3939 TEXAS BLVD |
Practice Address - Street 2: | |
Practice Address - City: | TEXARKANA |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75503-3207 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-255-6398 |
Practice Address - Fax: | 903-794-6305 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-05-14 |
Last Update Date: | 2012-05-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | PA00982 | 261QP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |