Provider Demographics
NPI:1013617851
Name:RENAISSANCE GRACE SERVICES LLC
Entity Type:Organization
Organization Name:RENAISSANCE GRACE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN-CHRISTOPHE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOUKELAK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:301-979-8104
Mailing Address - Street 1:12009 TREGONING PL
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-9365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12009 TREGONING PL
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-9365
Practice Address - Country:US
Practice Address - Phone:301-979-8104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No174200000XOther Service ProvidersMeals
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care