Provider Demographics
NPI:1184714966
Name:FISHER, RENATA (DC)
Entity type:Individual
Prefix:DR
First Name:RENATA
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5388
Mailing Address - Country:US
Mailing Address - Phone:309-788-4816
Mailing Address - Fax:
Practice Address - Street 1:3111 AVENUE OF THE CITIES
Practice Address - Street 2:SUITE # 1
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-4300
Practice Address - Country:US
Practice Address - Phone:309-781-4681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009799111N00000X
IA06545111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3732027OtherBCBS OF ILLINOIS
ILV05488Medicare UPIN
IL211812Medicare ID - Type Unspecified