Provider Demographics
NPI:1457770687
Name:RENAISSANCE MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADA
Authorized Official - Middle Name:X
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-362-2171
Mailing Address - Street 1:5502 S MCCOLL RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-8747
Mailing Address - Country:US
Mailing Address - Phone:956-362-2171
Mailing Address - Fax:956-362-2132
Practice Address - Street 1:5502 S MCCOLL RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8747
Practice Address - Country:US
Practice Address - Phone:956-362-2171
Practice Address - Fax:956-362-2132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX781566363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty