Healthcare Provider Details

I. General information

NPI: 1891216511
Provider Name (Legal Business Name): RENAISSANCE RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 SLATER AVENUE SUITE 111
FOUNTAIN VALLEY CA
92708-9270
US

IV. Provider business mailing address

10175 SLATER AVE STE 200
FOUNTAIN VALLEY CA
92708-4702
US

V. Phone/Fax

Practice location:
  • Phone: 203-450-8824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMIE COURTNEY
Title or Position: HUMAN RESOURCES
Credential:
Phone: 949-467-4801