Provider Demographics
NPI:1700379443
Name:REDEEMING HEARTS LLC
Entity Type:Organization
Organization Name:REDEEMING HEARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:VENBRUX
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:509-336-5972
Mailing Address - Street 1:1103 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2604
Mailing Address - Country:US
Mailing Address - Phone:509-336-5972
Mailing Address - Fax:
Practice Address - Street 1:1103 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2604
Practice Address - Country:US
Practice Address - Phone:509-336-5972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60249089101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCPC-6701OtherPROVIDER LICENSE STATE OF IDAHO
WALH60249089OtherPROVIDER LICENSE WA STATE