Provider Demographics
NPI:1609004084
Name:RENEW LIFE CENTER
Entity Type:Organization
Organization Name:RENEW LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIETA
Authorized Official - Middle Name:MARIMLA
Authorized Official - Last Name:GABIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-350-1700
Mailing Address - Street 1:211 DE ANZA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3989
Mailing Address - Country:US
Mailing Address - Phone:650-350-1700
Mailing Address - Fax:650-341-3604
Practice Address - Street 1:211 DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3989
Practice Address - Country:US
Practice Address - Phone:650-350-1700
Practice Address - Fax:650-341-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAG51233261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51233OtherMEDICAL LICENCE
AG2356548OtherDEA
CAG51233OtherMEDICAL LICENCE