Provider Demographics
NPI:1619274156
Name:RENATA B STURDIVANT
Entity Type:Organization
Organization Name:RENATA B STURDIVANT
Other - Org Name:REGIONAL WELLNESS ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:
Authorized Official - Last Name:STURDIVANT
Authorized Official - Suffix:
Authorized Official - Credentials:BS, RRT
Authorized Official - Phone:309-258-1194
Mailing Address - Street 1:3516 W MARY KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3727
Mailing Address - Country:US
Mailing Address - Phone:309-258-1194
Mailing Address - Fax:
Practice Address - Street 1:7503 RIVERSIDE PARK DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-4324
Practice Address - Country:US
Practice Address - Phone:309-258-1194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home