Healthcare Provider Details

I. General information

NPI: 1295072049
Provider Name (Legal Business Name): RENAISSANCE ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44139 MONTEREY AVE STE B
PALM DESERT CA
92260-8700
US

IV. Provider business mailing address

44139 MONTEREY AVE STE B
PALM DESERT CA
92260-8700
US

V. Phone/Fax

Practice location:
  • Phone: 760-773-4411
  • Fax: 760-773-2393
Mailing address:
  • Phone: 760-773-4411
  • Fax: 760-773-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL SAMUEL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 760-773-4411