Healthcare Provider Details

I. General information

NPI: 1063810091
Provider Name (Legal Business Name): RENEW ADDICTION TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 VENTERS LN STE 100
PIKEVILLE KY
41501-3016
US

IV. Provider business mailing address

PO BOX 1285
PIKEVILLE KY
41502-1285
US

V. Phone/Fax

Practice location:
  • Phone: 606-653-1505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number740318
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number740318
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number740318
License Number StateKY

VIII. Authorized Official

Name: MRS. AMBER SISCO
Title or Position: MANAGING MEMBER
Credential:
Phone: 606-653-1505