Provider Demographics
NPI:1144990367
Name:CONNER, RENEL J JR
Entity type:Individual
Prefix:
First Name:RENEL
Middle Name:J
Last Name:CONNER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3484 WOOD CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-6572
Mailing Address - Country:US
Mailing Address - Phone:513-668-3886
Mailing Address - Fax:
Practice Address - Street 1:3484 WOOD CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-6572
Practice Address - Country:US
Practice Address - Phone:513-668-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH053805174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist