Provider Demographics
NPI:1548746456
Name:RENEW WELLNESS CENTER
Entity Type:Organization
Organization Name:RENEW WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-868-6163
Mailing Address - Street 1:PO BOX 2691
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59403-2691
Mailing Address - Country:US
Mailing Address - Phone:406-453-9355
Mailing Address - Fax:844-274-1180
Practice Address - Street 1:2 5TH ST N STE 202
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-4011
Practice Address - Country:US
Practice Address - Phone:406-453-9355
Practice Address - Fax:844-274-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7178366Medicaid
MTKOVPYU3GGMedicaid