Provider Demographics
NPI:1407016660
Name:RENAISSANCE ADHC AT FOOTE ST
Entity Type:Organization
Organization Name:RENAISSANCE ADHC AT FOOTE ST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERYA
Authorized Official - Middle Name:LERA
Authorized Official - Last Name:BALANNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-506-6846
Mailing Address - Street 1:8945 NORTH WESTLAND DRIVE
Mailing Address - Street 2:#304
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877
Mailing Address - Country:US
Mailing Address - Phone:240-506-6846
Mailing Address - Fax:
Practice Address - Street 1:5214 FOOTE STREET, NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019
Practice Address - Country:US
Practice Address - Phone:202-388-6747
Practice Address - Fax:888-584-7137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC261QA0600X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care