Healthcare Provider Details

I. General information

NPI: 1407077217
Provider Name (Legal Business Name): RENAISSANCE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8733 BEVERLY BLVD #408
WEST HOLLYWOOD CA
90048
US

IV. Provider business mailing address

8733 BEVERLY BLVD #408
WEST HOLLYWOOD CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 310-360-0280
  • Fax: 310-360-0955
Mailing address:
  • Phone: 310-360-0280
  • Fax: 310-360-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A3999
License Number StateCA

VIII. Authorized Official

Name: MR. JENNY BENAVIDES
Title or Position: MEDICAL ASSISTANT
Credential: DO
Phone: 310-360-0280