Provider Demographics
NPI:1346630118
Name:WARE, RENITA
Entity Type:Individual
Prefix:
First Name:RENITA
Middle Name:
Last Name:WARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 COLFAX ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-1903
Mailing Address - Country:US
Mailing Address - Phone:219-885-4264
Mailing Address - Fax:
Practice Address - Street 1:1003 COLFAX ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46406-1903
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness