Provider Demographics
NPI:1902974678
Name:RENOVARE CLINIC OF NATURAL MEDICINE PA
Entity Type:Organization
Organization Name:RENOVARE CLINIC OF NATURAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GERHART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-776-0206
Mailing Address - Street 1:18301 NORTH 79TH AVE
Mailing Address - Street 2:SUITE G190
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:623-776-0206
Mailing Address - Fax:623-776-0282
Practice Address - Street 1:18301 NORTH 79TH AVE
Practice Address - Street 2:SUITE G190
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-776-0206
Practice Address - Fax:623-776-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7243111N00000X, 111NI0900X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z71954Medicare PIN