Provider Demographics
NPI:1952846719
Name:RENEGADE PERFORMANCE LLC
Entity Type:Organization
Organization Name:RENEGADE PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-765-3281
Mailing Address - Street 1:413 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1742
Mailing Address - Country:US
Mailing Address - Phone:607-765-3281
Mailing Address - Fax:
Practice Address - Street 1:3226 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-2670
Practice Address - Country:US
Practice Address - Phone:607-765-3281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011215111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty