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General NPI Number Information
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NPI Number | 1629816269
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Entity Type | Organization
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Legal Business Name | RENEWED LIFE LLC
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Dates
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Enumeration Date | 07/17/2024
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 115 W H ST STE 151
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-3426
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Country | US
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Telephone | 479-970-6454
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Fax |
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Provider Business Mailing Address
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Address Line | 115 W H ST STE 151
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-3426
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Country | US
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Telephone | 479-970-6454
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LINDA JO BANKSTON
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Credential | AADC, LADAC, LCSW
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Telephone | 479-970-6454
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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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Taxonomy #2
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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 #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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