Provider Demographics
NPI:1760749444
Name:A RENEWED MIND
Entity Type:Organization
Organization Name:A RENEWED MIND
Other - Org Name:A CITY OF COMPASSION DEVELOPMENT CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-330-5115
Mailing Address - Street 1:885 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5268
Mailing Address - Country:US
Mailing Address - Phone:419-330-1060
Mailing Address - Fax:419-931-6764
Practice Address - Street 1:1832 ADAMS ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604
Practice Address - Country:US
Practice Address - Phone:419-720-9247
Practice Address - Fax:419-422-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH141460Medicare UPIN