Provider Demographics
NPI:1043357726
Name:RENAISSANCE MEDICAL SPA, LLC
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PALMER
Authorized Official - Last Name:SNOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-524-9222
Mailing Address - Street 1:1414 E TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-3533
Mailing Address - Country:US
Mailing Address - Phone:812-524-9222
Mailing Address - Fax:812-524-9777
Practice Address - Street 1:1414 E TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3533
Practice Address - Country:US
Practice Address - Phone:812-524-9222
Practice Address - Fax:812-524-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047137261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN067386OtherSIHO
IN000000352813OtherANTHEM
IN=========OtherSAGAMORE
IN067386OtherSIHO
IN140790Medicare ID - Type Unspecified