Provider Demographics
NPI:1649729021
Name:RENAISSANCE PRIMARY CARE, LLC
Entity type:Organization
Organization Name:RENAISSANCE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:774-420-2311
Mailing Address - Street 1:11-15 SANDERSDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550
Mailing Address - Country:US
Mailing Address - Phone:774-420-2311
Mailing Address - Fax:508-519-0763
Practice Address - Street 1:11-15 SANDERSDALE ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550
Practice Address - Country:US
Practice Address - Phone:774-420-2311
Practice Address - Fax:508-519-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty