Provider Demographics
NPI:1134214109
Name:RENOVALES, CARMEN LUISA (RPT)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:LUISA
Last Name:RENOVALES
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE 59
Mailing Address - Street 2:BLOQUE 71 #12 SIERRA BAYAMON
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-0000
Mailing Address - Country:US
Mailing Address - Phone:787-565-4790
Mailing Address - Fax:787-778-4294
Practice Address - Street 1:CALLE 59
Practice Address - Street 2:BLOQUE 71 #12 SIERRA BAYAMON
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-0000
Practice Address - Country:US
Practice Address - Phone:787-565-4790
Practice Address - Fax:787-778-4294
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR00623174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR00623OtherPHYSICAL THERAPIST LICENC