Provider Demographics
NPI:1306217294
Name:RENECA CONTRACTING & CONSULTANT
Entity Type:Organization
Organization Name:RENECA CONTRACTING & CONSULTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:I
Authorized Official - Last Name:EFOBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-879-7707
Mailing Address - Street 1:1525 E PARK PLACE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3453
Mailing Address - Country:US
Mailing Address - Phone:770-879-7707
Mailing Address - Fax:770-879-7708
Practice Address - Street 1:1525 E PARK PLACE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3453
Practice Address - Country:US
Practice Address - Phone:770-879-7707
Practice Address - Fax:770-879-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-17
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060727261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service