Provider Demographics
NPI:1831661222
Name:RENEWAL GERIATRIC PRIMARY CARE PA
Entity Type:Organization
Organization Name:RENEWAL GERIATRIC PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-206-0115
Mailing Address - Street 1:4915 RATTLESNAKE HAMMOCK RD STE 156
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34113-6959
Mailing Address - Country:US
Mailing Address - Phone:239-206-0115
Mailing Address - Fax:239-307-2455
Practice Address - Street 1:4915 RATTLESNAKE HAMMOCK RD STE 156
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-6959
Practice Address - Country:US
Practice Address - Phone:239-206-0115
Practice Address - Fax:239-307-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-22
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty