Healthcare Provider Details

I. General information

NPI: 1336084540
Provider Name (Legal Business Name): RENEWED GRACE RESTORATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12785 ELMHURST DR
MORENO VALLEY CA
92555-2359
US

IV. Provider business mailing address

2550 CANYON SPRINGS PKWY STE 1096
RIVERSIDE CA
92507-0961
US

V. Phone/Fax

Practice location:
  • Phone: 951-268-0825
  • Fax:
Mailing address:
  • Phone: 951-268-0825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: WINNIKKIA PERKINS
Title or Position: OWNER
Credential:
Phone: 951-268-0825