Healthcare Provider Details

I. General information

NPI: 1073983763
Provider Name (Legal Business Name): RENAISSANCE ADHC @ FOOTE ST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5214 FOOTE ST NE
WASHINGTON DC
20019-6657
US

IV. Provider business mailing address

8945 N WESTLAND DR #304
GAITHERSBURG MD
20877
US

V. Phone/Fax

Practice location:
  • Phone: 240-506-6846
  • Fax:
Mailing address:
  • Phone: 240-506-6846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VALERYA LERA BALANNIK
Title or Position: PARTNER
Credential:
Phone: 240-506-6846