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General NPI Number Information
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NPI Number | 1548089261
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Entity Type | Organization
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Legal Business Name | RENEWED FOUNDATIONS LLC
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Dates
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Enumeration Date | 10/09/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 725 S WOODRUFF AVE STE 401
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5286
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Country | US
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Telephone | 208-360-1886
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Fax |
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Provider Business Mailing Address
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Address Line | 382 FIRE THORN
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City | IDAHO FALLS
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State | ID
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Zip | 83404-4954
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Country | US
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Telephone | 208-360-1886
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. SHAWN LAPRAY
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Credential |
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Telephone | 208-360-1886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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