MEDICARE: RENASCENCE PERSONAL CARE HOME 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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1316630296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENASCENCE PERSONAL CARE HOME LLC

Provider Business Mailing Address
First Line	:	3210 TACKETT RD
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30135-9104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3845 CYPRESS CREEK PKWY STE 350
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77068-3567
Country	:	US
Telephone Number	:	281-645-0880
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAKIMA JULES
Credential	:	NREMT-P
Telephone Number	:	678-979-6537

Provider Enumeration Date	:	05/29/2023
Last Update Date	:	05/29/2023

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