Provider Demographics
NPI:1558681106
Name:RENEW 4 LIFE LLC
Entity Type:Organization
Organization Name:RENEW 4 LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMPIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-520-1690
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0475
Mailing Address - Country:US
Mailing Address - Phone:208-520-1690
Mailing Address - Fax:
Practice Address - Street 1:240 S 5TH W STE E
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1476
Practice Address - Country:US
Practice Address - Phone:208-520-1690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-06
Last Update Date:2010-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health