Provider Demographics
NPI:1326116385
Name:RENAISSANCE HEALTHCARE INC
Entity Type:Organization
Organization Name:RENAISSANCE HEALTHCARE INC
Other - Org Name:ST MARY HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CORAZON
Authorized Official - Middle Name:C
Authorized Official - Last Name:APO
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:909-623-9972
Mailing Address - Street 1:750 TERRADO PLAZA
Mailing Address - Street 2:SUITE 119
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3411
Mailing Address - Country:US
Mailing Address - Phone:909-623-9972
Mailing Address - Fax:909-623-9970
Practice Address - Street 1:750 TERRADO PLAZA
Practice Address - Street 2:SUITE 119
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3411
Practice Address - Country:US
Practice Address - Phone:909-623-9972
Practice Address - Fax:909-623-9970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001493251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058311Medicare ID - Type UnspecifiedPROVIDER ID NUMBER