Provider Demographics
NPI:1699967992
Name:RENEW PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:RENEW PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:J
Authorized Official - Last Name:VARISCO
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:337-233-7701
Mailing Address - Street 1:19345 SUNSHINE AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8720
Mailing Address - Country:US
Mailing Address - Phone:985-809-3940
Mailing Address - Fax:985-809-3942
Practice Address - Street 1:19345 SUNSHINE AVENUE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-809-3940
Practice Address - Fax:985-809-3942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty