Healthcare Provider Details

I. General information

NPI: 1255485959
Provider Name (Legal Business Name): RENU LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 TINDERWOOD DR
GOLDSBORO NC
27534-7856
US

IV. Provider business mailing address

PO BOX 1017
GOLDSBORO NC
27533-1017
US

V. Phone/Fax

Practice location:
  • Phone: 919-734-0266
  • Fax: 919-734-9926
Mailing address:
  • Phone: 919-734-0266
  • Fax: 919-734-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberMHL-096-088
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-096-078
License Number StateNC

VIII. Authorized Official

Name: MRS. DIANE HARRISON
Title or Position: PRESIDENT
Credential:
Phone: 919-734-0266