MEDICARE: RENEW INTEGRATED PROGRAM-2 INC

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	251S00000X	Community/Behavioral Health Agency	A66124	CA

General Provider Information

NPI Number	:	1366883332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW INTEGRATED PROGRAM-2 INC

Provider Business Mailing Address
First Line	:	PO BOX 20140
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90801-3140
Country	:	US
Telephone Number	:	562-426-3300
Fax Number	:	562-637-3244

Provider Business Practice Location Address
First Line	:	9722 SAN ANTONIO AVE
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-4620
Country	:	US
Telephone Number	:	562-426-3300
Fax Number	:	562-637-3244

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. LAJA I IBRAHEEM
Credential	:	MD
Telephone Number	:	562-426-3300

Provider Enumeration Date	:	07/08/2013
Last Update Date	:	07/08/2013

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