Provider Demographics
NPI:1467282673
Name:RENEGADE RD LLC
Entity type:Organization
Organization Name:RENEGADE RD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPETILLO GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD
Authorized Official - Phone:936-349-6546
Mailing Address - Street 1:17350 STATE HIGHWAY 249 STE 220
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77064-1132
Mailing Address - Country:US
Mailing Address - Phone:936-349-6546
Mailing Address - Fax:
Practice Address - Street 1:909 BALSORA CV
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2637
Practice Address - Country:US
Practice Address - Phone:936-349-6546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty