Healthcare Provider Details

I. General information

NPI: 1548263791
Provider Name (Legal Business Name): RENEW HEALTH HOME AND HOME MEDICAL SUPPLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 PINE ST STE 103
MONTICELLO MN
55362-8564
US

IV. Provider business mailing address

PO BOX 1603
MONTICELLO MN
55362-1603
US

V. Phone/Fax

Practice location:
  • Phone: 763-295-6888
  • Fax: 763-295-6777
Mailing address:
  • Phone: 763-295-6888
  • Fax: 763-295-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. VICTOR KYLOCHKO
Title or Position: OWNER
Credential:
Phone: 763-295-6888