Basic Information
| Provider Information | |||||||||
| NPI: | 1619163409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENEWAL DERMATOLOGY AND LASER, APMC | ||||||||
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| Address1: | PO BOX 34120 | ||||||||
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| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895334120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757475050 | ||||||||
| FaxNumber: | 7753298596 | ||||||||
| Practice Location | |||||||||
| Address1: | 10870 BROCKWAY RD | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961612054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305500440 | ||||||||
| FaxNumber: | 5305828853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | KAMENETSKY | ||||||||
| AuthorizedOfficialFirstName: | DIANNE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5305500440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | G75315 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.