Provider Demographics
NPI:1972092989
Name:RENEW PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:RENEW PHYSICAL THERAPY AND WELLNESS, LLC
Other - Org Name:RENEW PHYSICAL THERAPY AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-228-2755
Mailing Address - Street 1:128 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54443-9411
Mailing Address - Country:US
Mailing Address - Phone:763-228-2755
Mailing Address - Fax:
Practice Address - Street 1:N2919 COUNTY ROAD QQ
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981
Practice Address - Country:US
Practice Address - Phone:763-228-2755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty