=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861825572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROJECT RENEWAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2013
-----------------------------------------------------
Last Update Date | 02/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 E 3RD ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-8908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-533-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 E 3RD ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-8908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-533-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MITCHELL NETBURN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-620-0340
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 160611600
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------