Provider Demographics
NPI:1891216511
Name:RENAISSANCE RECOVERY, LLC
Entity Type:Organization
Organization Name:RENAISSANCE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-397-6095
Mailing Address - Street 1:10175 SLATER AVENUE, SUITE 111
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10175 SLATER AVENUE SUITE 111
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-9270
Practice Address - Country:US
Practice Address - Phone:203-450-8824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA201716410068OtherOUT OF NETWORK INSURANCE