Provider Demographics
NPI:1073983763
Name:RENAISSANCE ADHC @ FOOTE ST
Entity Type:Organization
Organization Name:RENAISSANCE ADHC @ FOOTE ST
Other - Org Name:RENAISSANCE ADULT DAY HEALTHCARE CENTER AT FOOTE ST
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERYA
Authorized Official - Middle Name:LERA
Authorized Official - Last Name:BALANNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-506-6846
Mailing Address - Street 1:8945 N WESTLAND DR #304
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877
Mailing Address - Country:US
Mailing Address - Phone:240-506-6846
Mailing Address - Fax:
Practice Address - Street 1:5214 FOOTE ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-6657
Practice Address - Country:US
Practice Address - Phone:240-506-6846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC013078055Medicaid
DC078520900Medicaid