Provider Demographics
NPI:1356907182
Name:RENAISSANCE WELLNESS
Entity type:Organization
Organization Name:RENAISSANCE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYSTER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD; PHD
Authorized Official - Phone:757-782-2279
Mailing Address - Street 1:751 THIMBLE SHOALS BLVD STE M
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3563
Mailing Address - Country:US
Mailing Address - Phone:757-782-2279
Mailing Address - Fax:757-782-2313
Practice Address - Street 1:751 THIMBLE SHOALS BLVD STE M
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3563
Practice Address - Country:US
Practice Address - Phone:757-782-2279
Practice Address - Fax:757-782-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care