Healthcare Provider Details

I. General information

NPI: 1356678858
Provider Name (Legal Business Name): RENAISSANCE RESIDENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 SUMMER PLACE DR W
MOBILE AL
36618-3237
US

IV. Provider business mailing address

11673 MCFARLAND RD
SPANISH FORT AL
36527-5768
US

V. Phone/Fax

Practice location:
  • Phone: 251-300-4207
  • Fax:
Mailing address:
  • Phone: 251-621-3525
  • Fax: 251-621-3525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN TRENESE-WILLIAMS JONES
Title or Position: DIRECTOR
Credential: ED.S
Phone: 251-621-3525