Provider Demographics
NPI:1740670785
Name:RENEW OUT-PATIENT & RESIDENTIAL TREATMENT SERVICES LLC
Entity type:Organization
Organization Name:RENEW OUT-PATIENT & RESIDENTIAL TREATMENT SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:606-653-1505
Mailing Address - Street 1:PO BOX 678
Mailing Address - Street 2:
Mailing Address - City:BETSY LAYNE
Mailing Address - State:KY
Mailing Address - Zip Code:41605-0678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4963 US HIGHWAY 23 S
Practice Address - Street 2:SUITE 121
Practice Address - City:IVEL
Practice Address - State:KY
Practice Address - Zip Code:41642-9067
Practice Address - Country:US
Practice Address - Phone:606-653-1505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALCOHOL & DRUG ABUSE PREVENTION & TREATMENT SPECIALTIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY800139251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY800139OtherBEHAVIORAL HEALTH SERVICES ORGANIZATION
KY810407OtherALCOHOL AN OTHER DRUG TREATMENT ENTITY