Provider Demographics
NPI:1942438379
Name:RENEW PHYSICAL THERAPY AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:RENEW PHYSICAL THERAPY AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:301-613-2011
Mailing Address - Street 1:938 E SWAN CREEK RD
Mailing Address - Street 2:SUITE 269
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5250
Mailing Address - Country:US
Mailing Address - Phone:301-613-2011
Mailing Address - Fax:
Practice Address - Street 1:938 E SWAN CREEK RD
Practice Address - Street 2:SUITE 269
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5250
Practice Address - Country:US
Practice Address - Phone:301-613-2011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20141261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy