Provider Demographics
NPI:1760846232
Name:RENEW RESIDENTIAL TREATMENT SERVICES
Entity Type:Organization
Organization Name:RENEW RESIDENTIAL TREATMENT SERVICES
Other - Org Name:BROOKSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-658-3078
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-1285
Mailing Address - Country:US
Mailing Address - Phone:606-658-3078
Mailing Address - Fax:606-773-1011
Practice Address - Street 1:400 VENTERS LN
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3016
Practice Address - Country:US
Practice Address - Phone:606-653-1874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100851810Medicaid