MEDICARE: RENAISSANCE HEALTHCARE, 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	251J00000X	Nursing Care Agency

General Provider Information

NPI Number	:	1811487382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	1302 EDDINGTON DR.
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-1942
Country	:	US
Telephone Number	:	240-425-7428
Fax Number	:	866-531-6484

Provider Business Practice Location Address
First Line	:	1302 EDDINGTON DR
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-1942
Country	:	US
Telephone Number	:	240-425-7428
Fax Number	:	866-531-6484

Authorized Official
Title or Position	:	DON, CEO
Name	:	JANE AHWOREGBA SAMONS
Credential	:	RN, BSN
Telephone Number	:	240-425-7428

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	05/10/2018

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