Provider Demographics
NPI:1194463422
Name:RENEW RESIDENTIAL SERVICES LLC
Entity Type:Organization
Organization Name:RENEW RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CARREON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-575-2055
Mailing Address - Street 1:8109 DIAMOND PARK AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-7506
Mailing Address - Country:US
Mailing Address - Phone:330-575-2055
Mailing Address - Fax:
Practice Address - Street 1:2508 DEMINGTON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2446
Practice Address - Country:US
Practice Address - Phone:330-575-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-25
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0472182Medicaid