Basic Information
| Provider Information | |||||||||
| NPI: | 1710910385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENIKER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 171 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281179500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046604390 | ||||||||
| FaxNumber: | 7046604399 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281179500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046604390 | ||||||||
| FaxNumber: | 7046604399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 200300803 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 135MY | 01 | NC | NCBCBS | OTHER | 89135MY | 05 | NC | MEDICAID | N0080E | 05 | SC | MEDICAID |