Basic Information
| Provider Information | |||||||||
| NPI: | 1760142095 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RENEW, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RENEW VASCULAR INSTITUTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 OAK ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974012673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413025240 | ||||||||
| FaxNumber: | 5413442025 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 COBURG RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974017481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416818586 | ||||||||
| FaxNumber: | 5416818587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2021 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHALTRAW | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | ORGANIZER | ||||||||
| AuthorizedOfficialTelephone: | 5413027771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DIRECTOR RCM | ||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.