1407016660 NPI number — RENAISSANCE ADHC AT FOOTE ST

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 1407016660 NPI number — RENAISSANCE ADHC AT FOOTE ST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE ADHC AT FOOTE ST
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:
1407016660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8945 NORTH WESTLAND DRIVE
Provider Second Line Business Mailing Address:
#304
Provider Business Mailing Address City Name:
GAITHERSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-506-6846
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5214 FOOTE STREET, NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-388-6747
Provider Business Practice Location Address Fax Number:
888-584-7137
Provider Enumeration Date:
06/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BALANNIK
Authorized Official First Name:
VALERYA
Authorized Official Middle Name:
LERA
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
240-506-6846

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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