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General NPI Number Information
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NPI Number | 1750705158
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Entity Type | Organization
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Legal Business Name | RENEW LIFE, LLC
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Dates
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Enumeration Date | 02/06/2014
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Last Update Date | 02/06/2014
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Provider Practice Location Address
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Address Line | 11815 FOUNTAIN WAY STE 300
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-4448
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Country | US
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Telephone | 757-715-2117
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Fax |
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Provider Business Mailing Address
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Address Line | 11815 FOUNTAIN WAY STE 300
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-4448
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Country | US
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Telephone | 757-715-2117
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. MONIQUE EVANGELINE LACROIX
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Credential |
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Telephone | 757-715-2117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 382319-13
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License Number State | VA
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