Provider Demographics
NPI:1376090910
Name:RENAISSANCE RANCH OUTPATIENT, LLC
Entity Type:Organization
Organization Name:RENAISSANCE RANCH OUTPATIENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-680-1459
Mailing Address - Street 1:120 W 1470 S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-6798
Mailing Address - Country:US
Mailing Address - Phone:702-983-4464
Mailing Address - Fax:
Practice Address - Street 1:3037 E WARM SPRINGS RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3758
Practice Address - Country:US
Practice Address - Phone:435-680-1459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16330261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty