Healthcare Provider Details

I. General information

NPI: 1528543725
Provider Name (Legal Business Name): RENAISSANCE REJUVENATING MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 SW 4TH ST
CAPE CORAL FL
33991-1971
US

IV. Provider business mailing address

629 SW 4TH ST
CAPE CORAL FL
33991-1971
US

V. Phone/Fax

Practice location:
  • Phone: 239-800-3028
  • Fax: 239-599-4893
Mailing address:
  • Phone: 239-800-3028
  • Fax: 239-599-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALFONSO GARCIA BELLO
Title or Position: PRESIDENT
Credential: MD
Phone: 239-800-3028