Healthcare Provider Details

I. General information

NPI: 1194944363
Provider Name (Legal Business Name): RENAISSANCE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 W 5TH ST
LONDON KY
40741-1615
US

IV. Provider business mailing address

1380 W 5TH ST
LONDON KY
40741-1615
US

V. Phone/Fax

Practice location:
  • Phone: 606-878-0453
  • Fax: 606-878-1862
Mailing address:
  • Phone: 606-878-0453
  • Fax: 606-878-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES C GRAHAM
Title or Position: PRESIDENT
Credential:
Phone: 606-878-7522