Healthcare Provider Details

I. General information

NPI: 1376090910
Provider Name (Legal Business Name): RENAISSANCE RANCH OUTPATIENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3037 E WARM SPRINGS RD SUITE 400
LAS VEGAS NV
89120-3758
US

IV. Provider business mailing address

120 W 1470 S SUITE 100
ST GEORGE UT
84770-6798
US

V. Phone/Fax

Practice location:
  • Phone: 435-680-1459
  • Fax:
Mailing address:
  • Phone: 702-983-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number16330
License Number StateNV

VIII. Authorized Official

Name: MR. MICHAE KEENAN
Title or Position: OWNER
Credential:
Phone: 435-680-1459