Provider Demographics
NPI:1497319792
Name:RENEGADES FOR LIFE INC
Entity Type:Organization
Organization Name:RENEGADES FOR LIFE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SALEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-841-3700
Mailing Address - Street 1:10245 DES MOINES MEMORIAL DR S APT 401
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98168-1660
Mailing Address - Country:US
Mailing Address - Phone:206-841-3700
Mailing Address - Fax:
Practice Address - Street 1:1265 S MAIN ST STE 305A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2010
Practice Address - Country:US
Practice Address - Phone:206-841-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Multi-Specialty