Provider Demographics
NPI:1740907096
Name:RENEST RECOVERY SUPPORT SERVICES
Entity type:Organization
Organization Name:RENEST RECOVERY SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CADC
Authorized Official - Phone:270-839-6743
Mailing Address - Street 1:413 E DIXIE AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1162
Mailing Address - Country:US
Mailing Address - Phone:270-839-6743
Mailing Address - Fax:
Practice Address - Street 1:413 E DIXIE AVE STE 106
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1162
Practice Address - Country:US
Practice Address - Phone:270-839-6743
Practice Address - Fax:270-506-3253
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENEST RECOVERY SUPPORT SERVICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100811570Medicaid