Provider Demographics
NPI:1700337698
Name:LIFE RENEWAL SERVICES
Entity Type:Organization
Organization Name:LIFE RENEWAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-289-8149
Mailing Address - Street 1:PO BOX 1254
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-5254
Mailing Address - Country:US
Mailing Address - Phone:443-289-8149
Mailing Address - Fax:443-821-3280
Practice Address - Street 1:10805 HICKORY RIDGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3626
Practice Address - Country:US
Practice Address - Phone:443-289-8149
Practice Address - Fax:443-821-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health