MEDICARE: RENAISSANCE CARE, INC.

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1609884212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE CARE, INC.

Provider Business Mailing Address
First Line	:	1503 CARROLL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9779
Country	:	US
Telephone Number	:	260-637-5537
Fax Number	:	260-637-5537

Provider Business Practice Location Address
First Line	:	1503 CARROLL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9779
Country	:	US
Telephone Number	:	260-637-5537
Fax Number	:	260-637-5537

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MELANIE LYNN THELEN
Credential	:	RN, BSN
Telephone Number	:	260-637-5537

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/22/2020

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