Provider Demographics
NPI:1407077217
Name:RENAISSANCE HEALTH SERVICES
Entity Type:Organization
Organization Name:RENAISSANCE HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENAVIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-360-0280
Mailing Address - Street 1:8733 BEVERLY BLVD
Mailing Address - Street 2:#408
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:310-360-0280
Mailing Address - Fax:310-360-0955
Practice Address - Street 1:8733 BEVERLY BLVD
Practice Address - Street 2:#408
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-360-0280
Practice Address - Fax:310-360-0955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A3999207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93569Medicare UPIN