Provider Demographics
NPI:1912270075
Name:TIFFANY RENAUD, INC.
Entity Type:Organization
Organization Name:TIFFANY RENAUD, INC.
Other - Org Name:LIVING WELL SPINAL CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENAUD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:802-658-6092
Mailing Address - Street 1:3000 WILLISTON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6082
Mailing Address - Country:US
Mailing Address - Phone:802-658-6092
Mailing Address - Fax:802-863-9565
Practice Address - Street 1:3000 WILLISTON RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6082
Practice Address - Country:US
Practice Address - Phone:802-658-6092
Practice Address - Fax:802-863-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0002889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty