Provider Demographics
NPI:1316690472
Name:RENEW WEIGHT LOSS MARKETING LLC
Entity type:Organization
Organization Name:RENEW WEIGHT LOSS MARKETING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-577-4606
Mailing Address - Street 1:6344 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5408
Mailing Address - Country:US
Mailing Address - Phone:817-409-6265
Mailing Address - Fax:
Practice Address - Street 1:6344 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5408
Practice Address - Country:US
Practice Address - Phone:817-409-6265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-30
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1174117683OtherFAMILY PRACTICE