Provider Demographics
NPI:1346394012
Name:RENU LIFE EXTENDED, INC
Entity Type:Organization
Organization Name:RENU LIFE EXTENDED, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-0266
Mailing Address - Street 1:PO BOX 1017
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27533-1017
Mailing Address - Country:US
Mailing Address - Phone:919-734-0266
Mailing Address - Fax:919-734-9926
Practice Address - Street 1:201 WINDSOR CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-8696
Practice Address - Country:US
Practice Address - Phone:919-734-0266
Practice Address - Fax:919-734-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 311ZA0620X
NCHAL 096022320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804269Medicaid
NCMHL-096-277OtherDHSR
NC3408908Medicaid
NC1346394012Medicaid