Provider Demographics
NPI:1780877456
Name:RENEWED LIFE CENTER, LLC
Entity type:Organization
Organization Name:RENEWED LIFE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:NETTLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-467-4889
Mailing Address - Street 1:410 N. KINGS RD.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687
Mailing Address - Country:US
Mailing Address - Phone:208-467-4889
Mailing Address - Fax:208-467-4499
Practice Address - Street 1:410 N. KINGS RD.
Practice Address - Street 2:SUITE 3
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-467-4889
Practice Address - Fax:208-467-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)