1376090910 NPI number — RENAISSANCE RANCH OUTPATIENT, 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 1376090910 NPI number — RENAISSANCE RANCH OUTPATIENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE RANCH OUTPATIENT, 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:
1376090910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 W 1470 S
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84770-6798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-983-4464
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3037 E WARM SPRINGS RD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89120-3758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-680-1459
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KEENAN
Authorized Official First Name:
MICHAE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
435-680-1459

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  16330 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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