Provider Demographics
NPI:1962804112
Name:RENEW YOU THERAPIES & BEAUTY LLC
Entity type:Organization
Organization Name:RENEW YOU THERAPIES & BEAUTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TESLA
Authorized Official - Middle Name:HEIDI
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:208-546-9355
Mailing Address - Street 1:1111 S ORCHARD ST STE 160
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1977
Mailing Address - Country:US
Mailing Address - Phone:208-546-9355
Mailing Address - Fax:
Practice Address - Street 1:1111 S ORCHARD ST STE 160
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1977
Practice Address - Country:US
Practice Address - Phone:208-546-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-303225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0002158OtherMASSAGE