MEDICARE: RENEW HEALTH MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207VG0400X	Gynecology Physician
2	207Q00000X	Family Medicine Physician	GA
3	207R00000X	Internal Medicine Physician	GA

General Provider Information

NPI Number	:	1790238871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW HEALTH MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	1550 JANMAR RD STE B
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-5779
Country	:	US
Telephone Number	:	770-822-3031
Fax Number	:	770-822-3032

Provider Business Practice Location Address
First Line	:	1550 JANMAR RD STE B
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-5779
Country	:	US
Telephone Number	:	770-822-3031
Fax Number	:	770-822-3032

Authorized Official
Title or Position	:	OWNER
Name	:	PHARONDA LEE
Credential	:
Telephone Number	:	770-822-3031

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	01/31/2024

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Directions to “RENEW HEALTH MEDICAL CENTER LLC ” Practice Location

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