1639973720 NPI number — RENEWED HOPE WELLNESS CLINIC 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 1639973720 NPI number — RENEWED HOPE WELLNESS CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENEWED HOPE WELLNESS CLINIC 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:
1639973720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4209 LAKELAND DR # 378
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-9212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-209-3300
Provider Business Mailing Address Fax Number:
601-401-4326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 SAINT PAUL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEARL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39208-5134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-345-3700
Provider Business Practice Location Address Fax Number:
601-345-3750
Provider Enumeration Date:
04/01/2025

Additional Information

Authorized Official

Authorized Official Last Name:
BULLIE-THOMPSON
Authorized Official First Name:
BIANCA
Authorized Official Middle Name:
Authorized Official Title or Position:
FNP-C, PMHNP-BC
Authorized Official Telephone Number:
601-345-3700

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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