Healthcare Provider Details

I. General information

NPI: 1548746456
Provider Name (Legal Business Name): RENEW WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 5TH ST N STE 202
GREAT FALLS MT
59401-4011
US

IV. Provider business mailing address

PO BOX 2691
GREAT FALLS MT
59403-2691
US

V. Phone/Fax

Practice location:
  • Phone: 406-453-9355
  • Fax: 844-274-1180
Mailing address:
  • Phone: 406-453-9355
  • Fax: 844-274-1180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: STACY PETERSON
Title or Position: CO-OWNER
Credential:
Phone: 406-868-6163