Provider Demographics
NPI:1700295631
Name:RENEW PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:RENEW PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:CERALDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-517-1025
Mailing Address - Street 1:123 E LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3205
Mailing Address - Country:US
Mailing Address - Phone:815-517-1025
Mailing Address - Fax:815-901-0313
Practice Address - Street 1:123 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3205
Practice Address - Country:US
Practice Address - Phone:815-517-1025
Practice Address - Fax:815-901-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011875261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00240612OtherRR MEDICARE
ILP00240612OtherRR MEDICARE
K01043Medicare UPIN