Provider Demographics
NPI:1013606144
Name:SELF RENEW LLC
Entity Type:Organization
Organization Name:SELF RENEW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GEARHEART
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:606-369-3180
Mailing Address - Street 1:603 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-7746
Mailing Address - Country:US
Mailing Address - Phone:606-369-3180
Mailing Address - Fax:
Practice Address - Street 1:308 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1292
Practice Address - Country:US
Practice Address - Phone:606-369-3180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty