Organization
RENEW MEDICAL SPA LLC
Active
Other names
ReNew Medical Spa and Nutritional Wellness Center
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. THERESA M FONTENOT PA-C (OWNER)
(903) 255-6398
Entity
Organization
Contact information
Practice address
3939 TEXAS BLVD, TEXARKANA, TX 75503-3207
(903) 255-6398
(903) 794-6304
Mailing address
3939 TEXAS BLVD, TEXARKANA, TX 75503-3207
(903) 255-6398
(903) 794-6304
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
PA-190
AR
261QM2500X
Medical Specialty Clinic/Center
Primary
PA00892
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4995690001
CIGNA GOVERMENT SERVICES
TX
Enumeration date
09/13/2010
Last updated
02/06/2012
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