MEDICARE: RENU 2 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1073261889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENU 2 LLC

Provider Business Mailing Address
First Line	:	8010 BLAIR MILL WAY APT 207E
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-6805
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8010 BLAIR MILL WAY APT 207E
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-6805
Country	:	US
Telephone Number	:	202-494-6119
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ESONIJA SHAVON FULGHAM
Credential	:
Telephone Number	:	202-494-6119

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	07/14/2023

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