Provider Demographics
NPI:1003184789
Name:RENEW LIFE GROUP, LLC
Entity type:Organization
Organization Name:RENEW LIFE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNETTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-291-0078
Mailing Address - Street 1:8410 SUTTONVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 C-JAMES STREET
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4737
Practice Address - Country:US
Practice Address - Phone:910-291-0078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty