Provider Demographics
NPI:1174810766
Name:RENOVO CLINIC
Entity type:Organization
Organization Name:RENOVO CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:SEALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-214-5099
Mailing Address - Street 1:2680 S VAL VISTA DR
Mailing Address - Street 2:SUITE 187
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2152
Mailing Address - Country:US
Mailing Address - Phone:480-214-5099
Mailing Address - Fax:866-368-5410
Practice Address - Street 1:2680 S VAL VISTA DR
Practice Address - Street 2:SUITE 187
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-2152
Practice Address - Country:US
Practice Address - Phone:480-214-5099
Practice Address - Fax:866-368-5410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARDMORE INSTITUTE OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service