Provider Demographics
NPI:1821022815
Name:RENEW THERAPY CENTER OF PORT ST. LUCIE , LLC
Entity Type:Organization
Organization Name:RENEW THERAPY CENTER OF PORT ST. LUCIE , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAZARO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-501-8804
Mailing Address - Street 1:1854 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5545
Mailing Address - Country:US
Mailing Address - Phone:772-501-8804
Mailing Address - Fax:
Practice Address - Street 1:1854 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34952-5545
Practice Address - Country:US
Practice Address - Phone:772-501-8804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC3926261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684856Medicare PIN