Provider Demographics
NPI:1134408214
Name:RENOVUS MEDICAL SPA
Entity type:Organization
Organization Name:RENOVUS MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-207-0154
Mailing Address - Street 1:405 ROY MARTIN RD
Mailing Address - Street 2:STE 104
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2551
Mailing Address - Country:US
Mailing Address - Phone:423-207-0154
Mailing Address - Fax:
Practice Address - Street 1:405 ROY MARTIN RD
Practice Address - Street 2:STE 104
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-2551
Practice Address - Country:US
Practice Address - Phone:423-207-0154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17509305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3025259Medicare PIN