MEDICARE: RENAISSANCE WELLNESS ACADEMY, LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1104794130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE WELLNESS ACADEMY, LLC.

Provider Business Mailing Address
First Line	:	6877 NW 179TH ST APT 107
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-7451
Country	:	US
Telephone Number	:	786-593-0317
Fax Number	:

Provider Business Practice Location Address
First Line	:	6877 NW 179TH ST APT 107
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-7451
Country	:	US
Telephone Number	:	786-593-0317
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VICTOR R. EVINS
Credential	:	RMHCI
Telephone Number	:	786-593-0317

Provider Enumeration Date	:	10/29/2025
Last Update Date	:	10/29/2025

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