Provider Demographics
NPI:1275075020
Name:PROJECT RENEWAL INC
Entity Type:Organization
Organization Name:PROJECT RENEWAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:NETBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-620-0340
Mailing Address - Street 1:200 VARICK ST
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-4810
Mailing Address - Country:US
Mailing Address - Phone:212-620-0340
Mailing Address - Fax:
Practice Address - Street 1:225 E 45TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-3301
Practice Address - Country:US
Practice Address - Phone:212-661-8934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002161R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01921402Medicaid
NY01921402Medicaid
NY331101Medicare PIN