MEDICARE: RENAISSANCE HEALTH CARE 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	314000000X	Skilled Nursing Facility	050002151	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518939404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	6050 S 800 E-92
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9201
Country	:	US
Telephone Number	:	260-625-3545
Fax Number	:	260-625-3328

Provider Business Practice Location Address
First Line	:	6050 S 800 E-92
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9201
Country	:	US
Telephone Number	:	260-625-3545
Fax Number	:	260-625-3328

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DEB I MILLS
Credential	:
Telephone Number	:	260-625-3545

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	11/18/2011

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