Provider Demographics
NPI:1972205003
Name:RENEW PHYSICAL THERAPY AND WELLNESS LLC
Entity Type:Organization
Organization Name:RENEW PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEDER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:904-599-5459
Mailing Address - Street 1:424 GENTIAN RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6426
Mailing Address - Country:US
Mailing Address - Phone:904-599-5459
Mailing Address - Fax:
Practice Address - Street 1:424 GENTIAN RD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6426
Practice Address - Country:US
Practice Address - Phone:904-599-5459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy