Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH9701 | FL |
N | 111NN1001X | Nutrition | X2538 | NY |
NPI | 1619976743 |
---|---|
Provider Name | Stephen Renick JR. |
First Address | Ocoee, FL 34761-4752 |
Second Address | Ocoee, FL 34761-4752 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2005 |
Last Update Date | 05/03/2009 |