=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447828926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENEWED HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2021
-----------------------------------------------------
Last Update Date | 06/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 E PLAZA CIR DR # 555C
-----------------------------------------------------
City | LITCHFIELD PARK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85340-4922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-521-4204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 E PLAZA CIR DR # 555C
-----------------------------------------------------
City | LITCHFIELD PARK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85340-4922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. JESUS ANTONIO LOVETT II
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-521-4204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------