Provider Demographics
NPI:1033479993
Name:RENEW INTEGRATED PROGRAM-2 INC.
Entity Type:Organization
Organization Name:RENEW INTEGRATED PROGRAM-2 INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAJA
Authorized Official - Middle Name:I
Authorized Official - Last Name:IBRAHEEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-426-3300
Mailing Address - Street 1:4000 LONG BEACH BLVD
Mailing Address - Street 2:228
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2617
Mailing Address - Country:US
Mailing Address - Phone:562-426-3300
Mailing Address - Fax:562-637-3244
Practice Address - Street 1:14135 FAIRGROVE AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-1708
Practice Address - Country:US
Practice Address - Phone:562-426-3300
Practice Address - Fax:562-637-3244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66124251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7205Medicaid