=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972088516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENEWED MEDICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2018
-----------------------------------------------------
Last Update Date | 11/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29787 JOHN J WILLIAMS HWY #6
-----------------------------------------------------
City | MILLSBORO
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19966-4097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-648-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29787 JOHN J WILLIAMS HWY #6
-----------------------------------------------------
City | MILLSBORO
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19966-4097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-648-2733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. ADAEZA UDEZUE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 302-648-2733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------