Healthcare Provider Details

I. General information

NPI: 1619470556
Provider Name (Legal Business Name): TOTAL RENAISSANCE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8926 BALTIMORE ST
SAVAGE MD
20763-7549
US

IV. Provider business mailing address

PO BOX 363
SAVAGE MD
20763-0363
US

V. Phone/Fax

Practice location:
  • Phone: 443-718-9223
  • Fax:
Mailing address:
  • Phone: 443-718-9223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LINDIWE FIARRA GREENWOOD
Title or Position: CEO
Credential: M.D.
Phone: 443-718-9223