Provider Demographics
NPI:1578849634
Name:RENEWED VITALITY LLC
Entity Type:Organization
Organization Name:RENEWED VITALITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:RICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:682-554-2000
Mailing Address - Street 1:9535 FOREST LANE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243
Mailing Address - Country:US
Mailing Address - Phone:214-389-1234
Mailing Address - Fax:214-389-1230
Practice Address - Street 1:9535 FOREST LANE
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:214-389-1234
Practice Address - Fax:214-389-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty