Provider Demographics
NPI:1720808686
Name:RENEWAL BOUTIQUE
Entity type:Organization
Organization Name:RENEWAL BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-533-3282
Mailing Address - Street 1:24401 HEALTH CENTER DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3615
Mailing Address - Country:US
Mailing Address - Phone:949-328-9026
Mailing Address - Fax:949-328-9187
Practice Address - Street 1:24401 HEALTH CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3615
Practice Address - Country:US
Practice Address - Phone:949-328-9026
Practice Address - Fax:949-328-9187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-15
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies