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General NPI Number Information
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NPI Number | 1366237000
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Entity Type | Organization
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Legal Business Name | RENEW U THERAPY
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Dates
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Enumeration Date | 04/12/2025
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Last Update Date | 04/12/2025
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Provider Practice Location Address
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Address Line | 12319 MOUNT VERNON AVE
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City | GRAND TERRACE
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State | CA
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Zip | 92313
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Country | US
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Telephone | 951-217-9363
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8461
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City | MORENO VALLEY
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State | CA
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Zip | 92552-8461
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Country | US
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Telephone | 951-217-9363
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SIAMAK EHTESHAMZADEH
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Credential | DR.
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Telephone | 951-217-9363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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