Healthcare Provider Details

I. General information

NPI: 1285117325
Provider Name (Legal Business Name): RENOVO CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E BURR BLVD
KEARNEYSVILLE WV
25430-4793
US

IV. Provider business mailing address

150 E BURR BLVD
KEARNEYSVILLE WV
25430-4793
US

V. Phone/Fax

Practice location:
  • Phone: 681-252-1632
  • Fax: 300-455-3743
Mailing address:
  • Phone: 681-252-1632
  • Fax: 300-455-3743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number465
License Number StateWV

VIII. Authorized Official

Name: MELISSA SWARTZ
Title or Position: FOUNDER/CLINICAL DIRECTOR
Credential:
Phone: 681-252-1632