Provider Demographics
NPI:1013436641
Name:RENEW MANUAL PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:RENEW MANUAL PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BREANN
Authorized Official - Middle Name:FAYE SUDDOCK
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, PRPC
Authorized Official - Phone:602-515-6659
Mailing Address - Street 1:7444 W SAXTON DR # K101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1316
Mailing Address - Country:US
Mailing Address - Phone:602-515-6659
Mailing Address - Fax:
Practice Address - Street 1:7444 W SAXTON DR # K101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-1316
Practice Address - Country:US
Practice Address - Phone:602-515-6659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5245225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID=========OtherIRS