Healthcare Provider Details

I. General information

NPI: 1194169359
Provider Name (Legal Business Name): RENAISSANCE RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 S UTAH AVE
IDAHO FALLS ID
83402-3321
US

IV. Provider business mailing address

1165 S UTAH AVE
IDAHO FALLS ID
83402-3321
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-6155
  • Fax:
Mailing address:
  • Phone: 208-522-6155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DAVID PINEGAR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-522-6155