Provider Demographics
NPI:1649600834
Name:RENAISSANCE SOUTH LA
Entity Type:Organization
Organization Name:RENAISSANCE SOUTH LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:III
Authorized Official - Credentials:MBA
Authorized Official - Phone:323-872-6352
Mailing Address - Street 1:19401 S VERMONT AVE
Mailing Address - Street 2:SUITE C-100
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19401 S VERMONT AVE
Practice Address - Street 2:SUITE C-100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1029
Practice Address - Country:US
Practice Address - Phone:855-700-7752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-25
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA190796AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty