Provider Demographics
NPI:1558587824
Name:REMEDIES RENEWING LIVES
Entity Type:Organization
Organization Name:REMEDIES RENEWING LIVES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF MARKETING/FUND DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-966-1285
Mailing Address - Street 1:215 EASTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2203
Mailing Address - Country:US
Mailing Address - Phone:815-962-0871
Mailing Address - Fax:815-962-7895
Practice Address - Street 1:215 EASTON PKWY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-962-0871
Practice Address - Fax:815-962-7895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0559-0005-A261QM2800X
ILA-0559-0005--A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid