Healthcare Provider Details

I. General information

NPI: 1376211540
Provider Name (Legal Business Name): RENEWAL MN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 HENNEPIN TOWN RD
EDEN PRAIRIE MN
55347-5100
US

IV. Provider business mailing address

7358 N LINCOLN AVE STE 160
LINCOLNWOOD IL
60712-1797
US

V. Phone/Fax

Practice location:
  • Phone: 952-444-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: ELIEZER MEYSTEL
Title or Position: MANAGER
Credential:
Phone: 847-983-8750