MEDICARE: RENAISSANCE WELLNESS, 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	208VP0000X	Pain Medicine Physician	ME22595	FL

General Provider Information

NPI Number	:	1922248830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE WELLNESS, LLC

Provider Business Mailing Address
First Line	:	3880 COLONIAL BLVD
Second Line	:	SUITE 2
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1062
Country	:	US
Telephone Number	:	239-590-3883
Fax Number	:	239-590-3884

Provider Business Practice Location Address
First Line	:	3880 COLONIAL BLVD
Second Line	:	SUITE 2
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1062
Country	:	US
Telephone Number	:	239-590-3883
Fax Number	:	239-590-3884

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KONSTANTINE K YANKOPOLUS
Credential	:	M.D.
Telephone Number	:	239-590-3883

Provider Enumeration Date	:	03/05/2009
Last Update Date	:	07/31/2013

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