Provider Demographics
NPI:1770654378
Name:RENEE LAURITZEN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RENEE LAURITZEN MD A PROFESSIONAL CORPORATION
Other - Org Name:PACIFIC ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LAURITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-542-9678
Mailing Address - Street 1:1500 PALM ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2998
Mailing Address - Country:US
Mailing Address - Phone:805-542-9678
Mailing Address - Fax:805-542-9685
Practice Address - Street 1:1500 PALM ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2998
Practice Address - Country:US
Practice Address - Phone:805-542-9678
Practice Address - Fax:805-542-9685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77320207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G773200OtherBLUE SHIELD
CAG77320OtherBLUE CROSS
CAW20489Medicare UPIN