Provider Demographics
NPI:1487900718
Name:RENUEVATE PA
Entity type:Organization
Organization Name:RENUEVATE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-567-2236
Mailing Address - Street 1:119 RETAMA STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELSA
Mailing Address - State:TX
Mailing Address - Zip Code:78543
Mailing Address - Country:US
Mailing Address - Phone:956-567-2236
Mailing Address - Fax:956-567-2013
Practice Address - Street 1:119 RETAMA STREET
Practice Address - Street 2:SUITE C
Practice Address - City:ELSA
Practice Address - State:TX
Practice Address - Zip Code:78543
Practice Address - Country:US
Practice Address - Phone:956-567-2236
Practice Address - Fax:956-567-2013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty