Provider Demographics
NPI:1922248830
Name:RENAISSANCE WELLNESS, LLC
Entity Type:Organization
Organization Name:RENAISSANCE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KONSTANTINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:YANKOPOLUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-590-3883
Mailing Address - Street 1:3880 COLONIAL BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1062
Mailing Address - Country:US
Mailing Address - Phone:239-590-3883
Mailing Address - Fax:239-590-3884
Practice Address - Street 1:3880 COLONIAL BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1062
Practice Address - Country:US
Practice Address - Phone:239-590-3883
Practice Address - Fax:239-590-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22595208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61926Medicare UPIN