Provider Demographics
NPI:1205443504
Name:RENOVIS HEALTH LLC
Entity type:Organization
Organization Name:RENOVIS HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:OLISAELOKA
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-470-7318
Mailing Address - Street 1:29155 NORTHWESTERN HWY # 515
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1011
Mailing Address - Country:US
Mailing Address - Phone:800-960-1463
Mailing Address - Fax:
Practice Address - Street 1:26206 W 12 MILE RD STE 302
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8501
Practice Address - Country:US
Practice Address - Phone:424-303-0544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-30
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty