1194583963 NPI number — RENAISSANCE MEDICAL MANAGEMENT LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194583963 NPI number — RENAISSANCE MEDICAL MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE MEDICAL MANAGEMENT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194583963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
941 W I-35 FRONTAGE ROAD STE 116 PMB 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-285-6901
Provider Business Mailing Address Fax Number:
405-285-6902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3509 FRENCH PARK DR STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73034-7291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-285-6901
Provider Business Practice Location Address Fax Number:
405-285-6902
Provider Enumeration Date:
03/07/2024

Additional Information

Authorized Official

Authorized Official Last Name:
WATTS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER, MEDICAL DOCTOR
Authorized Official Telephone Number:
405-205-7424

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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