Provider Demographics
NPI:1962512434
Name:RENEAU, KEVIN (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RENEAU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 WILTSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-1083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:803 N THOMPSON LN
Practice Address - Street 2:SUITE A-103
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-4329
Practice Address - Country:US
Practice Address - Phone:615-890-7610
Practice Address - Fax:615-890-9352
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN779OtherLICENSE #