Healthcare Provider Details

I. General information

NPI: 1366151136
Provider Name (Legal Business Name): IDEAL HOPE RENAISSANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/21/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N LEE TREVINO DR STE A
EL PASO TX
79936-4549
US

IV. Provider business mailing address

1701 N LEE TREVINO DR STE A
EL PASO TX
79936-4549
US

V. Phone/Fax

Practice location:
  • Phone: 915-262-4664
  • Fax:
Mailing address:
  • Phone: 915-262-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: KENNETH O EKECHUKWU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 215-496-0518