Provider Demographics
NPI:1598204844
Name:RENEW WEIGHT LOSS LLC
Entity Type:Organization
Organization Name:RENEW WEIGHT LOSS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-362-6334
Mailing Address - Street 1:2659 COMMERCIAL ST SE
Mailing Address - Street 2:STE 236
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4445
Mailing Address - Country:US
Mailing Address - Phone:503-362-6334
Mailing Address - Fax:503-391-9555
Practice Address - Street 1:2659 COMMERCIAL ST SE
Practice Address - Street 2:STE 236
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4445
Practice Address - Country:US
Practice Address - Phone:503-362-6334
Practice Address - Fax:503-391-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty