Provider Demographics
NPI:1063069276
Name:HARDMAN, RENWOOD ANDRE
Entity type:Individual
Prefix:
First Name:RENWOOD
Middle Name:ANDRE
Last Name:HARDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 E PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1514
Mailing Address - Country:US
Mailing Address - Phone:386-281-8867
Mailing Address - Fax:
Practice Address - Street 1:1660 E PARADISE LN
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1514
Practice Address - Country:US
Practice Address - Phone:386-281-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLH635-721-89-244-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver