=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770430969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENAISSANCE PORT INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2026
-----------------------------------------------------
Last Update Date | 03/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18600 FLORENCE ST
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-775-8764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28401 MOUND RD UNIT 1810
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48090-7264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-775-8764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | NICOLE L COMER
-----------------------------------------------------
Credential | ADMINISTRATOR
-----------------------------------------------------
Telephone | 877-775-8764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------