Healthcare Provider Details

I. General information

NPI: 1780256123
Provider Name (Legal Business Name): RENAISSANCE VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27900 BRODIAEA AVE
MORENO VALLEY CA
92555-5700
US

IV. Provider business mailing address

27900 BRODIAEA AVE
MORENO VALLEY CA
92555-5700
US

V. Phone/Fax

Practice location:
  • Phone: 951-379-0100
  • Fax:
Mailing address:
  • Phone: 951-379-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: LATONYA DAVIS
Title or Position: EXECUTIVE DIRECTOR
Credential: LVN
Phone: 951-379-0100