Healthcare Provider Details

I. General information

NPI: 1568977940
Provider Name (Legal Business Name): RENAISSANCE MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 BLEVINS BOULEVARD
BRISTOL VA
24202
US

IV. Provider business mailing address

284 BLEVINS BOULEVARD
BRISTOL VT
24202
US

V. Phone/Fax

Practice location:
  • Phone: 276-285-3911
  • Fax: 276-285-3920
Mailing address:
  • Phone: 276-285-3911
  • Fax: 276-285-3920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE OLIVER HALSTEAD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 276-285-3911