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General NPI Number Information
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NPI Number | 1568977940
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Entity Type | Organization
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Legal Business Name | RENAISSANCE MEDICAL CARE
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Dates
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Enumeration Date | 12/07/2017
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Last Update Date | 03/25/2019
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Provider Practice Location Address
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Address Line | 284 BLEVINS BOULEVARD
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City | BRISTOL
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State | VA
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Zip | 24202
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Country | US
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Telephone | 276-285-3911
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Fax | 276-285-3920
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Provider Business Mailing Address
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Address Line | 284 BLEVINS BOULEVARD
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City | BRISTOL
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State | VT
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Zip | 24202
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Country | US
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Telephone | 276-285-3911
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Fax | 276-285-3920
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Authorized Official
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Title or Position | PRESIDENT
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Name | GEORGE OLIVER HALSTEAD
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Credential | M.D.
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Telephone | 276-285-3911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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